CHAPTER III.

DYSMENORRHEA.

DYSMENORRHEA is the condition in which the menstrual process gives rise to pain in the pelvic organs. The pain may precede or accompany the flow. It may be due to diseases of the ovaries, the tubes, the uterus, the pelvic peritoneum, or connective tissue, or be of purely nervous origin. If the dysmenorrhea is due to inflammation of the uterine appendages and the contiguous part of the peritoneum and connective tissue, it appears, as a rule, earlier as much as eight days before the flow begins-and a relief is felt when the congestion is diminished by the physiological rupture of capillaries taking place in the mucous membrane (p. 117). The pain is situated in the sides of the pelvis or the iliac fossæ. Sometimes it seems to be due merely to a toughness in the texture of the ovary which interferes with the free development of the Graafian follicle.

If the dysmenorrhea comes from the uterus itself, it may be due to inflammation of the mucous membrane or the muscular tissue (endometritis or parenchymatous metritis). There may be an intrauterine polypus playing the rôle of a ball valve, or the simple swelling of the mucous membrane, especially at the internal os, may prevent the escape of the blood from the cavity, or the uterus may be so bent that the crookedness of its canal opposes a barrier to the free outflow of the blood.

It is especially anteflexion which predisposes to dysmenorrhea, but the more pronounced cases of retroflexion have a similar effect. The cervical canal may be too narrow, especially at the internal or external os (stenosis). Sometimes clots are formed in the uterus, the expulsion of which causes labor-like pain in the back and behind the symphysis. Sometimes the whole mucous membrane is thrown off and expelled with similar pains-a condition called membranous dysmenorrhea.

Uterine dysmenorrhea is felt more centrally and appears a shorter time before the appearance of the flow, and continues often for several days after it has begun.

That dysmenorrhea which is due to closure of the genital canal and retention of the menstrual blood has already been mentioned in the chapter on Amenorrhea (p. 239).

Nervous dysmenorrhea may be due to over-sensitiveness of the nerves, so that the normal congestion of menstruation is perceived as a painful pressure, and it may be caused by muscular contraction of the internal os.

The degree of dysmenorrhea varies from a slight discomfort to the most excruciating pain, that unfits the patient for any work and almost makes life unendurable.

Prognosis. The prognosis varies, especially with the etiology. In most cases we may promise relief, if not a cure.

Treatment.-The treatment varies likewise very much with the causes. In young, undeveloped girls, without any inflammatory complications, we try to avoid a vaginal examination. Even a rectal one may be dispensed with for some time. Tonics (p. 226), exercise in open air, gymnastics (p. 191), general massage (p. 190), towel-baths, shower-baths, and sea-bathing (p. 188), are the chief remedies. Where there is any form of inflammation exercise can only be taken with great caution and within narrow limits, and the patient ought to stay in bed during the attack. The treatment of the special diseases causing dysmenorrhea will be found under the description of the diseases of the different organs, but for convenience's sake we will briefly refer to it here.

In all inflammatory conditions we use hot vaginal injections (p. 171), painting of the vaginal roof with tincture of iodine (p. 170), pledgets with glycerin, iodine-glycerin, or ichthyol-glycerin (p. 178), faradization with the secondary current (p. 229), galvanism or scarification of the vaginal portion (p. 186). In endometritis we make applications to the endometrium (p. 170).

In anteflexion the regular use of the uterine sound gives great relief. A retroflexed womb is replaced and a Hodge's pessary introduced into the vagina. Outerbridge's intra-uterine drainage pessary (p. 184) may prove useful. For flexions or mere stenosis the cervical canal is dilated with Hanks' and Garrigues' dilators (p. 155), either moderately (below half an inch) or to the full extent of the latter instrument (divulsion). The narrow canal may also be gradually dilated with the negative pole of the galvanic battery. In cervical anteflexion it may become necessary to split the posterior lip of the cervix (Sims's operation). In desperate cases of dysmenorrhea due to inflammation of the ovaries and tubes salpingo-oophorectomy is the last resort.

The purely nervous dysmenorrhea is treated with tonics and sedatives (p. 226).

During the attack all forms need some immediate relief. Since these conditions often last long and a baneful habit might be acquired, we should be careful not to abuse narcotics, but in bad cases they are unavoidable. I often use an anti-dysmenorrheic pill of the following composition:

R. Extr. conii alc.,

Extr. strammon. alc.,

Extr. opii,

Ft. pil. No. x.

Sig. One pill at most three times a day.

Эј;

āā. gr. v.

In the milder cases hot dry or wet fomentations of the abdomen,

and hot drinks, such as hot tea or hot brandy and water or an infusion of anthemis or matricaria, may suffice. Antipyrin (gr. x), antifebrin (gr. v), and phenacetin (gr. viiss) should all be tried before narcotics are used; and they have often splendid effect. If necessary, a second dose is given after an hour, and a third after three hours. Viburnum prunifolium is also a uterine sedative: since the taste and odor of the fluid extract are most offensive to many patients, it is well to give it inspissated in capsules (dose 3j of the fluid extract, t. i. d.).

Among the older drugs apiol (a capsule with my from three to six times a day), pulsatilla (mij-iij of the fluid extract in water, three or four times a day during the week preceding menstruation), and cannabis Indica (20 drops of the tincture every three hours during the pain), are yet praised.

There is a widespread popular belief that marriage is a panacea for all sufferings in a girl, but nothing could be more erroneous. If marital relations may work as a stimulus, like electricity, to imperfectly developed genitals, calm an irritated nervous system, effectually cure a stenosis or flexion, by the occurrence of conception and childbirth, on the other hand inflammatory conditions of the pelvic organs get much worse by the congestion produced by coition and the stretching of all the organs unavoidably connected with pregnancy and childbirth (p. 129).

CHAPTER IV.

PRECOCIOUS AND TARDY MENSTRUATION.

A SINGLE discharge of blood from the genitals is sometimes found in little children, even in the new-born, without any apparent disease. Irregular bleeding may take place from a sarcoma. But we can only speak of precocious menstruation when there is a regular return of the bleeding from the genitals every four weeks in children below the age of puberty. This is a very rare affection. It has been observed in a child less than a year old, and several cases are on record dating from the second year. As a rule, both the external and internal genitals and the breasts are abnormally developed in such children, and sometimes they show sexual appetite. Their constitution suffers under the untimely loss of blood. There is nothing to be done for them except to try to combat the general weakness, keep them quiet at the time of menstruation, and watch them in regard to masturbation. To check the flow might lead to vicarious menstruation.

Tardy menstruation is the first appearance of the menstrual flow at an unusually advanced age. It has been seen to begin as late as thirty-one years. This condition has been considered under the subject of Amenorrhea.

CHAPTER V.

MENORRHAGIA.

MENORRHAGIA is too great a loss of blood from the uterus at the time menstruation is due. The increased loss may either be due to a shortening of the intermenstrual period, or to a protracted duration of the flow, or, most of all, to an increase of the amount lost at each period. Since the normal amount is not known, and, at all events, varies much, we cannot indicate in an exact way where menorrhagia begins, but, practically, we call the flow so if it suddenly becomes much more profuse than the woman usually has it, and if it weakens

her.

Etiology.-Menorrhagia is in most cases due to a disease of the uterus, such as endometritis, chronic metritis, subinvolution, lacerated cervix, a granular condition of the os, a fibroid tumor, a polypus, or cancer. It may also be due to the different kinds of displacements of the uterus. Secondly, it may be due to ovarian diseases, especially oophoritis and small ovarian tumors. Thirdly, certain general acute infectious diseases are apt to cause profuse menstruation, especially cholera, small-pox, scarlet fever, typhoid fever, and inflammatory rheumatism. Among the chronic diseases hemophilia, syphilis, chlorosis, and malaria especially give rise to profuse menstruation.

Sometimes the cause is to be sought in diseases of the heart, the liver, or the kidneys.

Sometimes no cause can be assigned-e. g. for the not infrequent menorrhagia found in young girls at the beginning of menstrual life. Symptoms.-Besides the increased loss of blood, there are other symptoms due to it. If the loss is very heavy, it may cause acute anemia with rapid, flagging pulse, dyspnea, pallor, cold clammy skin, faintness, or syncope. But oftener we find a chronic anemia characterized by pallor, weakness, asthenopia, and backache.

Diagnosis. The diagnosis between menorrhagia and metrorrhagia i.e. uterine hemorrhage occurring independently of menstruation -is sometimes difficult or impossible when so frequent hemorrhages take place that the patient does not herself know what would be the regular time for a menstrual flow to come on; but in most cases the distinction can be made by the time elapsed since the last bleeding, by the sensations which generally precede the menstrual flow, by the

admixture of mucus with the blood, and by the gradual way in which it appears.

Prognosis. It is doubtful if ever a woman has died directly of menorrhagia, but repeated losses undermine health and shorten life. Treatment. In the mildest cases we prescribe ergot and other internal hemostatics (p. 227), rest, cool diet, and abstinence from alcoholic drinks and coffee. The bowels should be kept open with saline aperients (p. 225). If there is any excitement, bromides and opiates, especially opium suppositories (p. 226), are indicated. If this treatment does not have the desired effect, vaginal injec tions with hot water may be added. If they do not check the hemorrhage, we add liq. ferri chloridi to the water (p. 182). If the bleeding continues, an intra-uterine injection of hot water with or without liq. ferri is given (p. 172). A bag with hot water applied to the lumbar region is sometimes effective. An ice-bag is placed over the symphysis (p. 187). If all this is ineffectual, or if the hemorrhage is alarming, we tampon the vagina (p. 179) or the uterus (p. 180).

In the intermenstrual period a treatment is instituted according to the cause of the menorrhagia. If the endometrium is affected, the uterus is treated with applications of liquor ferri (p. 170), curetted (p. 176), or cauterized by means of chemical galvano-cauterization (p. 233) with the positive pole in the uterus. Granulations are destroyed, the torn cervix united, a polypus removed, and a fibroid treated as taught under the discussion of that disease. Ovarian inflammation is treated with injections, applications, resolvents (p. 226), glycerin pledgets, galvanism, etc.

At the same time we try by means of hemostatics, tonics, and food to build up the patient as much as possible before the occurrence of the next menstruation (pp. 224-228).

In cases of heart disease a moderate bleeding gives relief, and should, therefore, not be checked too soon. Digitalis, strophanthus, and aconite are valuable remedies under such circumstances. When the liver is torpid, attention to diet, abstention from alcoholic drinks, and the administration of calomel, pulv. hydrargyri cum creta, or euonymin (gr. ss-v) are indicated. In kidney disease especial attention should be paid to the vicarious functions of the skin and bowels.

The physician must not forget that a moderate loss of blood is a normal condition, a kind of safety-valve, for the female economy. He must, therefore, allow a reasonable amount of blood to escape before he begins to check the flow. As a rule, I let patients suffering from menorrhagia bleed from two to four days before interfering, but a dangerous loss of blood should be stopped at any time by the most potent measures. How to act in a given case can only be learned by tact and experience. If everything else fails to check menorrhagia, Tait recommends the removal of the appendages.