CHAPTER VI. METRORRHAGIA. METRORRHAGIA is a profuse uterine hemorrhage occurring at another time than the menstrual flow. Its causes, symptoms, and treatment are essentially the same as those of menorrhagia, just described, with the exception that this flow, being entirely abnormal, need not be allowed, and may, therefore, be treated more actively from the very beginning, unless the bleeding has a beneficial influence on some diseased condition-e. g. pelvic inflammation. CHAPTER VII. GENERAL MENSTRUAL DISORDERS. THE menstrual process being a general condition of which the secretion of blood from the mucous membrane of the uterus is only one feature, there is hardly any part of the body in which we may not find more or less important disturbances connected with it. These occur especially before the flow appears or in the beginning of the same. They may accompany a normal bloody discharge from the genitals, but are more commonly combined with amenorrhea or scanty menstruation. The Nervous System.-Headache, especially in the shape of migraine, is quite common, Sometimes neuralgic pains are felt, especially in the arms and legs. Hysteria may be entirely due to menstrual disorders or get worse at every period. In exceptional cases it may reach the highest degree, so-called hystero-epilepsy. True epilepsy may only appear at the time of impending menstruation, or the attacks may be worse every time the period recurs. In insane women the influence of menstruation is very marked. As a rule, maniacal attacks get worse or appear only at that time. Symptoms of impulsive insanity, such as kleptomania or the impulse to murder, are sometimes decidedly increased by menstruation. insanity of girls at puberty, especially that pyromania which drives them to set houses or hayricks on fire irrespective of consequences, may be parallelized with that of the menopause which we have already mentioned (p. 124). The The Eyes.-Existing inflammation gets very frequently worse. In those suffering from exophthalmic goiter the eyes are more prominent. The condition known as hysteric copiopia1 acquires generally increased 1 This disease, described by Foerster, is characterized by pain in the region of the intensity. Blood may be extravasated into the anterior camera or behind the retina. Papillary inflammation, optic neuritis, neuro-retinitis, and complete amaurosis have been observed. The formation of sties is very common. The Ear-Vicarious menstruation may occur from the ear. Existing granulations swell; purulent discharge, buzzing sound, and deafness increase frequently. The Nose.-Profuse epistaxis may be due to vicarious menstruation. The skin is often the seat of exanthemata, such as acne, urticaria, eczema, exudative erythema, herpes, etc. The latter appears not infrequently on the genitals, which also are liable to become the prey of pruritus. The legs and the face may become edematous. Sometimes there is free perspiration, with or without an unpleasant smell, or seborrhea of the scalp. Besides vicarious menstruation in the shape of blood trickling out through fissures forming in the skin, there are sometimes minute ecchymoses in the same. The Digestive Tract.-Sometimes the tongue is coated; the patient suffers from toothache, aphthous stomatitis, or sore throat. As mentioned above, the stomach may be the seat of vicarious menstruation, from a few teaspoonfuls to over two pounds of blood being vomited. There may also be a hemorrhoidal flow or diarrhea. In rarer cases a dull pain in the right hypochondrium betokens a congestion of the liver, which may even lead to jaundice. The Respiratory System.-The thyroid body swells not infrequently, especially in those afflicted with goiter, and this swelling may cause such a compression of the trachea that tracheotomy becomes necessary. We have mentioned above that the lungs are one of the seats of predilection for vicarious menstruation. This hemorrhage may be dangerous in itself, and may be a precursor of phthisis. The circulatory system does not suffer much, except that palpitations are not uncommon, and that angiomas and varicose veins are liable to increase. The Urinary Organs.-The sufferings due to floating kidney become worse during the congestion preceding menstruation. There is a frequent desire of evacuating the urine, and the bladder may be the seat of vicarious menstruation. conjunctival fold, in or behind the eye, the forehead, less frequently in the malar bones or the superior maxilla, and by a peculiar kind of photophobia experienced in regard to artificial light in a dark room, besides a great variety of hyperesthetic phenomena. It attacks both eyes. It is incurable, but disappears spontaneously, often after many years. It is frequent in the higher classes, and is by far more common in women than in men. It is said in the former to be a reflex neurosis from chronic parametritis. As treatment it is recommended to let the patient take drachm of Canadian castoreum and 1 drachm of extract of valerian in the course of four days, which gives relief for several weeks. At the same time the patient should use eye-drops with acetate of zinc (W. A. Freund, Gynäkologische Klinik, Strasburg, 1885, vol. i. pp. 265-272). The Genitals.-Displaced ovaries may become particularly painful, and the swelling of the ovary enclosed in a hernia may give rise to strangulation. Fibroids often grow larger, and intra-uterine polypi may be pushed down into the cervix or the vagina. In cases of atresia we have seen that the pain increases at each new outpouring of blood that finds no vent. Leucorrhea precedes or follows very frequently the menstrual flow, or appears, as stated above, as a substitute for it. The breasts not uncommonly become swollen and painful, and they are one of the more frequent seats of vicarious menstruation. Patients affected with divers chronic diseases often feel more discomfort during menstruation. It is claimed that amenorrhea, without the presence of any other disease, may cause edema and ascites, and that menstruation has a very bad effect on the progress of osteomalacia. Treatment. In all affections connected with amenorrhea or scanty menstruation the first indication is to try to bring on or increase the menstrual flow, except in those cases in which there is a general debility that, presumably, would be made worse by any loss of blood. Under these latter circumstances the first thing to do is to strengthen the general health. Secondly, the different special disturbances call for treatment. Headache and neuralgia are often relieved by the administration of phenacetin, antipyrin, antifebrin, caffeine (gr. j to iij t. i. d.), or the combination called effervescent granulated bromo-caffeine (a heaping teaspoonful), pulv. paulliniæ (gr. xx, t. i. d.), extr. cannabis (gr. to, or 20 to 40 minims of the tincture, t. i. d.). A favorite combination of mine is M.-Div. in ptt. aequ. No. xii. Det. ad chart. cerat. In regard to the treatment of the manifold other disturbances mentioned above we must refer the reader to works on the practice of medicine, special treatises, and later chapters of this Manual.' Those familiar with German may find much valuable information in Leopold Meyer's Der Menstruationsprozess und seine Krankhaften Abweichungen, Stuttgart, 1890. P. S. BRUGUIERE, M. D. PART VIII. LEUCORRHEA. NORMALLY, the genital tract is just moist enough to be soft and slippery; nowhere a drop of fluid is visible. Any mucous, serous, or purulent discharge is abnormal, and constitutes in itself a disease or is a symptom of one. The word "leucorrhea" means a white flow, but it is used to designate any discharge other than blood coming from the genitals. Popularly the disorder is called "the whites." The discharge may come from the vulva, the vagina, the neck or the body of the womb. That from the vulva and the vagina is acid, that from the uterus alkaline. The microscope reveals flat epithelial cells in vulvar and vaginal leucorrhea, an abundance of mucous corpuscles in the cervical, and columnar epithelial cells, sometimes ciliated, in that coming from the uterus, be it from the neck or the body (p. 51). The fluid is serous, mucous, or purulent, and may have an admixture of a little blood. It may be colorless, white, yellow, green, red, or brown. The white color is due to the presence of epithelial cells, the yellow to pus, the red to fresh blood, and the brown to decomposed blood. It may be nearly as thin as water or more or less thick like cream and soft cheese. A colorless, thick fluid like the raw white of an egg is exclusively secreted by the goblet-shaped cells found in the depressions between the branches of the arbor vitæ (p. 5).49 Leucorrhea is idiopathic, specific, or symptomatic. A leucorrhea is called idiopathic when it is not due to any permanent structural anatomical lesion. It is then constitutional and forms a disease in itself. The specific leucorrhea is that due to gonorrheic infection. A leucorrhea is symptomatic when it is one symptom among others of a certain disease. Causes.-1. Idiopathie Leucorrhea.'-Like other catarrhal affections, and often combined with them, it may be due to a cold, damp climate or residence. It may be connected with plethora or anemia. It may be induced by anything that weakens the constitution, such as protracted lactation, bodily or mental fatigue, emotions, especially of a depressing kind, and insufficient nourishment. It occurs frequently in persons predisposed to pulmonary phthisis. It is some Fordyce Barker's paper, "Leucorrhea considered in Relation to its Constitutional Causes and Treatment," Trans. Amer. Gyn. Soc., 1882, vii. pp. 130-141, contains many valuable hints on this topic that has disappeared from many modern treatises on gynecology. times brought on by local irritation, such as masturbation, frequent coition, gravidity, childbirth, or abortion; or it appears in consequence of amenorrhea or scanty menstruation as a supplementary or vicarious menstruation, not only during the period of menstrual life, but frequently after the climacteric has been established. In this way it may also take the place of lactation, suppressed perspiration, hemorrhoidal flow, diarrhea, and other discharges. 2. The specific leucorrhea due to gonorrheic infection will be considered under Vaginitis. 3. Symptomatic Leucorrhea.-It may be a symptom of rheumatism, scrofulosis, tuberculosis, malaria; of numerous local diseases of the genitals, such as vulvitis, colpitis, endometritis, metritis, subinvolution, granulations at the os or in the interior of the womb, ulcers, a lacerated cervix, polypi, fibroids, sarcoma, carcinoma; or of diseases in other organs which interfere with a free circulation in the genitals, such as disease of the heart and the liver. Symptoms.-The leucorrheic discharge is a drain on the system, which has given rise to the popular belief that the white stuff coming out of the genitals is the spinal marrow that melts. While it may be brought on by anemia, it may also lead to it. The patients complain of weakness, backache, neuralgia in different parts of the body, and often an irritable bladder. Commonly they suffer from anorexia and dyspepsia. Frequently there are menstrual disturbances, especially too frequent, too long, and too copious menstruation, or, on the other hand, amenorrhea. Local changes in the cervix and the vagina, especially excoriations, ulcerations, granulations, and eversion of the inucous membrane, may be due to the irritation caused by the discharge, just as we find vegetations, eczema, erythema, intertrigo springing up in the groins, at the vulva, and on the inside of the thighs. Prognosis. Since leucorrhea is found under such extremely different conditions, nothing can be said in a general way about the prognosis. It depends mostly on the cause. Treatment. The same applies to the treatment, but here we may add that, as a rule, a general and a local treatment should go hand in hand. The more the condition depends on constitutional causes, the more general treatment is needed, and the more powerful it is; the more local disease predominates, the more actively must the leucorrhea be combated in its seat. The most substantial food and invigorating drinks that the stomach can digest must be given (p. 224), and digestion is to be helped artificially if necessary. The patient must have a passage once in twentyfour hours. She must wear sufficiently warm clothes, especially woolen underwear (pp. 128 and 168). Tonic medicines (p. 226), general massage (p. 190), gymnastics (p. 191), and exercise in the open air, are useful. Change of climate, locality, and surroundings is a great |