Class. 
 Book 
 
 COPYRIGHT DEPOSIT 
 
borders of Menstruation. 
 
 EDWARD W. JENKS M. D , LL. D., 
 
 Professor of Gynecology in the Michigan College of Medicine and Surgery, 
 
 Fellow of the American Gynecological Society and o/ the Ol stetri- 
 
 cal Society of London; Ho?iorary Member^of the Cincinnati 
 
 Obstetrical Society; Corresponding Member of Boston 
 
 Gynecological Society; President ('£7-66 )'j>f the 
 
 Detroit Gynecological Society , Etc., Etc. 
 
 Valeat quantum Vulere potest. 
 
 1888. 
 GEORGE S. DAVIS, 
 
 DETROIT, MICH. 
 
 "^ 
 

 Copyrighted by 
 GEORGE S. DAVIS. 
 
&& 
 
 TO MY FORMER PUPILS 
 
 «5"? 
 
 MANY OF WHOM, FULFILLING THEIR YOUTHFUL PREDILEC- 
 TIONS, HAVE ATTAINED DISTINCTION AND RENOWN, BUT NOW 
 SCATTERED THROUGHOUT MANY LANDS; IN COMMEMORATION 
 OF PAST ASSOCIATIONS AND IN RECOGNITION OF MANY FRIEND- 
 SHIPS WHICH NEITHER TIME NOR DISTANCE CAN LESSEN, THIS 
 LITTLE WORK IS AFFECTIONATELY DEDICATED 
 
 BY THE AUTHOR. 
 
DISORDERS OF MENSTRUATION. 
 
 In considering the subject of disorders of men- 
 struation, it is not the purpose of the author of this 
 little monograph to discuss the physiology of men- 
 struation, notwithstanding the subject is very interest- 
 ing, and might be regarded as appropriate in such a 
 connection, nor will the causes of menstruation be 
 considered, notwithstanding the fact that there have 
 been many learned and ingenious theories promul- 
 gated and brought to the attention of the medical 
 world within the past few years. It is the sole pur- 
 pose of the author to set before his readers only that 
 which will serve to be pre-eminently practical to the 
 busy practitioner. 
 
 Readers are referred to the larger text books and 
 works on special subjects to find discussions of 
 theories relating to the causes or the physiology of 
 menstruation. 
 
 The subject will be taken up in the following 
 order: ist., Amenorrhcea; 2nd., Menorrhagia and 
 Metrorrhagia; 3rd., Dysmenorrhcea; 4th., Derange- 
 ments of the Climacteric. 
 
 AMENORRHCEA. A 
 
 This term designates the absence of the men- 
 strual flow between the ages of puberty and its final 
 cessation. Amenorrhcea should not be confounded 
 with retained menses due to occlusion of any portion 
 
of the parturient canal, or when it is normally absent, 
 as during pregnancy or lactation. 
 
 Causes; Amenorrhcea may be due, to some 
 local affection or to lack of development of the 
 generative organs or to pathological changes which 
 may have taken place in some one of them ; it 
 may be attributed to debility, in consequence of 
 some constitutional or local disease ; exposure 
 to cold though unattended by constitutional dis- 
 turbances, may be a starting cause ; mental emo- 
 tions such as grief, disappointment, etc.; sedentary 
 habits, indigestion and such chronic disorders as 
 phthisis, repeated hemorrhage from the lungs or other 
 parts of the body. In chlorotic and anaemic patients 
 amenorrhea is often present and is desirable rather 
 than otherwise, as in such patients if menstruation oc- 
 curs it is liable to become a profuse hemorrhage. 
 
 Diagnosis: In this climate menstruation occurs 
 between the ages of thirteen and fifteen as a rule, but 
 there are many instances of its earlier and of its later 
 occurrence. If a girl has reached the maximum age 
 and there are external signs of development such as 
 enlargement of the breasts, development of the figure, 
 etc., without menstruation making its appearance, 
 particularly if there are indications of the molimen, 
 there is usually some obstruction such as an imperfor- 
 ate hymen, or atresia, which a physical examination 
 alone can determine. 
 
 It is very important that one should be certain as 
 
to the existence or non-existence of pregnancy, and if 
 the physician is in doubt, the wisest course is to wait 
 for time to make its revelations on this point. In 
 extra-uterine pregnancy there is usually either en- 
 tire absence of or scanty menstruation. The same 
 may be be said concerning the existence of ovarian 
 tumors. 
 
 Lack of development of the ovaries is occasionally 
 a cause of amenorrhcea but it is more often the cause 
 of scanty menstruation. 
 
 Treatment: In cases where puberty is delayed in 
 otherwise strong and healthy girls, and if there are in- 
 dications of the menstrual molimen no special treat- 
 ment is necessary beyond encouraging such pursuits 
 as are likely to develop the bodily and mental func- 
 tions. In cases of undeveloped uteri and ovaria good 
 food, healthy exercise, good hygienic surroundings are 
 of the greatest service in improving the nutrition of 
 these organs. As to remedies under these circum- 
 stances it may be said in a general way that tonics and 
 electricity are the most efficacious. Medicines do but 
 little good except as they improve the general healths 
 If amenorrhcea exists in consequence of debility from 
 either general or local disease no special treatment is 
 demanded unless the amenorrhcea persists for a long 
 time after full restoration to health. Although the 
 treatises upon materia medica mention many remedies 
 under the head of emmenagogues, it may be truly said 
 that there is no one of them that can be relied upon. 
 
— 4 — 
 
 In anaemic and chlorotic patients iron may be of serv- 
 ice, particularly with the former on account of its im- 
 proving the condition of the blood. General galvan- 
 ism improves the tone of the entire economy, while 
 galvanism applied to the uterus and over the ovaries, 
 stimulates the nutrition of these organs, and thus as- 
 sists in their development and aids in the establish- 
 ment of the menstrual flow. Stimulating applications 
 to the uterine cavity frequently have a similar effect. 
 The following case may be of interest as illustra- 
 tive of tardy menstruation due to two causes, the main 
 cause being overshadowed by the lesser: 
 
 Miss. E., aged 24, first consulted me two and a 
 half years ago. She was a fairly well developed girl 
 and externally there was nothing to indicate non-de- 
 velopmeriu She stated that she had at the age of 
 eighteen begun to menstruate and menstruated reg- 
 ularly for about four months, since which time there 
 has been no signs externally of the menstrual flow. 
 There was the molimen increasing in severity, and 
 often prostrating and disabling her for days at a time. 
 She had taken quantities of medicine prescribed by 
 different physicians to bring about menstruation, but 
 without avail. After a long time she consented to 
 have an examination made. On attempting to make 
 the examination she was so uncontrollable that it could 
 not be completed, but it seemed that an imper- 
 forate hymen existed. It was not until April, 1887, 
 at my private hospital, that a thorough examination 
 was made, first per rectum and later per vaginam with 
 the patient fully anaesthetized by ether. It was then 
 found that one ovary was virtually absent as it was so 
 
— 5 — 
 
 diminutive, there being but a rudiment of one. The 
 other ovary was fully developed. The uterus was 
 what is termed "one-horned." The portion upon the 
 side of the undeveloped ovary was in an equally un- 
 developed state. While under ether the hymen, which 
 was almost imperforate (the opening being only a pin- 
 hole), was removed and a sound passed into the uterus. 
 Since then the treatment has been of a stimulating 
 character locally, and of a tonic character constitution- 
 ally. About five months after this menstruation ap- 
 peared and has since recurred regularly every four 
 weeks, although the flow is rather scanty. Her gen- 
 eral health simultaneously began to improve and she 
 now presents a healthful and quite robust appearance. 
 She herself says that she is in far better health than 
 she has been at any time since her 18th birthday. 
 
 Another interesting case was that of Mrs. F., a 
 robust, well-developed woman, 32 years <.i age, who 
 consulted me with reference to the possibility of her 
 becoming pregnant. There was every indication of 
 the development of the ovaries, but the uterus was 
 imperfectly developed, its entire cavity measuring 
 about one and one-half inches in length. Menstrua- 
 tion had always been scanty, and for the two preced- 
 ing years had barely made its appearance a few times ; 
 notwithstanding, every month there was the molimen, 
 accompanied by many distressing symptoms. For two 
 years and a half she was treated from two to four times 
 per week by galvanism and stimulating intra-uterine 
 applications. At the end of this time the uterine 
 cavity measured a trifle over two and one-fourth 
 inches, menstruation had become regularly established, 
 and on returning for treatment it was found that the 
 menses had not appeared at the expected time, there- 
 fore she was advised to have nothing, done, as there 
 
— 6 — 
 
 were some symptoms of pregnancy. The surmise 
 proved to be correct and she has since borne two 
 children. 
 
 In chlorotic and anaemic patients, particularly in 
 the former, other remedies than iron are required, 
 arsenic and strychnia being frequently of great ser- 
 vice; also the mineral acids and bitter tonics, where 
 the digestion is impaired. The author has found the 
 following prescriptions beneficial in very many cases: 
 
 9 Acidi arsen., gr. ij. 
 
 Strychnia, gr. j. 
 
 Acidi hydrochlor., 3 ss. 
 
 Tr. ferrimur., § iss. 
 
 Aquae, q. s. ad § iv. 
 
 M. Sig. — Take a teaspoonful in water thrice daily after 
 meals. 
 
 For patients whose stomachs are weak or peculiar- 
 ly susceptible to the influence of arsenical prepara- 
 tions, this mixture maybe diluted with glycerine; one- 
 half to one ounce of the latter may be added to four 
 ounces of the mixture, with the result of making it 
 more acceptable to the stomach, as well as disguising 
 the taste. 
 
 Parke, Davis & Co. also make a triturate tablet 
 containing iron, arsenic and strychnine, which can be 
 prescribed where the bitter taste of the foregoing mix- 
 ture is objected to. The following is an excellent 
 combination of mineral acid and bitter tonic. 
 1J Acidi nitro-mur. dil., 3 iiss. 
 
 Tr. cinchonas comp., q. s. ad § iv. 
 
 M. Sig. — Take a teaspoonful in water three times a day 
 just before meals. 
 
— 7 — 
 
 Aloes has long enjoyed a reputation as an em- 
 menagogue, and is valuable in cases of suppression. 
 The author has been in the habit of using the aloetic 
 and myrrh pill of the pharmacopoeia. Of late per- 
 manganate of potash has been highly commended. 
 Oil of savin, madder, and the gossypium, may all be 
 of service. When menstruation is about due, the us e 
 of hot foot and hip baths are valuable aids, but of no 
 advantage at other times. In conjunction with the 
 hip or foot baths hot drinks, such as an infusion of 
 pennyroyal leaves, drank upon retiring, often proves 
 of great benefit. In cases where there is either com- 
 plete absence or a scanty flow, stimulating applica- 
 tions, such as Churchill's tincture of iodine, or carbolic 
 acid, or the iodized phenol, may often be applied to 
 the endometrium, with satisfactory results. 
 
 As these preparations will frequently be referred 
 to, it may be a matter of convenience for the formulae 
 to be here given: 
 
 Churchill's tincture of iodine is prepared as fol- 
 lows: 
 
 I£ Iodine (crystals), 3 v. 
 
 Iodide of potassium, 3 i. 
 
 Rectified spirits, § iij. 
 
 Alcohol, § i. 
 M. 
 
 There is another preparation called Churchill's 
 tincture which contains less iodine and more iodide 
 of potassium than the above. 
 
There will be frequent references in these pages 
 to a saturated tincture of iodine that is used in the 
 place of Churchill's tincture and which is prepared as 
 follows: 
 
 ^ Iodine (crystals), 3 ijss. 
 
 Iodide of potassium, 3 iij- 
 
 Alcohol, % ij. 
 M. 
 
 The combination of iodine and carbolic acid 
 known as iodized phenol originated with Dr. Robert 
 Battey, and is as follows: 
 
 IJ Iodine (crystals), 3 ij. 
 
 Carbolic acid (crystals), § j. 
 M. 
 
 For ordinary office use it is advisable in many in- 
 stances to dilute the iodized phenol one-half with 
 alcohol or glycerin, or alcohol and glycerine. 
 
 Glycerin added to any of these preparations of 
 iodine is useful in preventing an escharotic effect. 
 
 Often the simple passage of a sound is effica- 
 cious, if applied about the time the flow is due. The 
 galvanic stem pessary is highly extolled by some 
 gynaecologists; but the galvanic current by means 
 of an intra-uterine electrode is of greater value. 
 
 The author believes that here a word of caution 
 is requisite concerning local treatment, namely, all 
 intra-uterine applications or treatment, should be 
 scrupulously avoided if there is a tenderness of the 
 uterus or its annexes in consequence of an active con- 
 
— 9 — 
 
 gestion, or from any other cause than a mere hyper- 
 esthesia. 
 
 It should be borne in mind that local treat- 
 ment in this affection js not demanded except where 
 there is imperfect development of either the ovaries 
 or uterus. The practitioner will occasionally meet 
 with exceptions to this general rule. Where there is 
 a lack of development the general plan of treatment 
 may be said to be of a stimulating character, as for 
 instance, the use of electricity and other treatment 
 heretofore mentioned. While an effort is made to im- 
 prove the general health of the patient, stimulating ap- 
 plications of various sorts may be used within the va- 
 gina, and the safest course is the wisest. Douches of hot 
 water administered while the patient is upon her back, 
 using each time one quart of a temperature ranging 
 from 105 ° to 112 F., are sometimes of service when 
 the circulation is defective. It may seem paradoxical 
 to prescribe the use of hot water here to increase the 
 amount of blood in the pelvic organs and later to pre- 
 scribe the same remedy in other disorders for the pur- 
 pose of decreasing it. But the reader will observe 
 that there is a marked difference in the quantity used 
 in these two diverse conditions; in the former the 
 primary effect or an increase of the peripheral blood 
 is desired, therefore a small quantity (one to three 
 pints) is used; while in the latter the secondary or a 
 decrease of the peripheral blood is desired, produced 
 by constringing the capillaries, therefore a large quan- 
 
IO 
 
 tity (one to three gallons) is used. To illustrate what 
 is meant, if one will place his hand in hot water two 
 minutes he will find, on removal, the surface red and 
 swollen; whereas, if it remain fifteen or twenty min- 
 utes the skin will present a blanched and wrinkled 
 appearance. 
 
 A stimulating application locally applied is a 
 solution of boro-glyceride and alum with glycer- 
 ine by means of tampons of absorbent cotton. This 
 application will improve the circulation of the pelvic 
 organs, and like all preparations of glycerine applied 
 to mucous surfaces will cause a profuse watery flow. 
 
 A formula for the above preparation for office 
 use is as follows: 
 
 Boro-glyceride, 
 Alum, of each, i part. 
 Pure Glycerine, 14 parts. 
 
 After using the above, and there is to be found indica- 
 tions of uterine catarrh or an atrophied condition of 
 the endometrium, it is often advisable to dilate the 
 cervix uteri and make stimulating applications to the 
 uterine cavity. The author's favorite preparation is 
 iodized phenol, on account of the anaesthetic proper- 
 ties of carbolic acid causing this application to be less 
 painful than other preparations in general use. 
 
 Suspension of the menses, particularly in plethoric 
 women, is frequently attended with febrile symptoms, 
 with severe pain in the hypogastric region and in the 
 head, and occasionally, with patients of this sort, there 
 
II 
 
 will be symptoms indicative of articular rheumatism, 
 which will rapidly disappear upon the appearance of 
 the flow. At other times there will be myalgia or so- 
 called muscular rheumatism, which also will disap- 
 pear, as by magic, as soon as the menstrual flow is 
 re-instated. In the form attended by febrile symp- 
 toms there will occasionally be one that may be 
 benefitted by the use of leeches — a mode of treatment 
 more common in the past than at the present time. 
 For the majority of patients, however, a saline cathar- 
 tic will be sufficient; in the meantime the hot douches 
 and hot foot or hip baths should be used. Sinapisms 
 may be applied with service to the hypogastrium, over 
 the sacrum or on the inner side of the thighs. The 
 condition of the skin should always be looked to and 
 its health should be maintained by baths. 
 
 Not unfrequently there are symptoms calling for 
 the administration of anodynes. While some of the 
 preparations of opium are of great service, extreme care 
 should be exercised on the part of the physician about 
 prescribing this drug. There is no class of disorders 
 more frequently the starting point of the opium habit 
 than those of menstruation. In instances of amenor- 
 rhea, if there is any reason for suspecting the patient 
 may be pregnant, great caution is necessary on the 
 part of the physician, lest in his desire to do good he 
 may unwittingly do harm. No evil result would fol- 
 low the administration of saline laxatives, hot douches 
 or simple applications to the neck of the uterus. But 
 
12 
 
 intra-uterine examinations or applications should be 
 scrupulously avoided until the physician is convinced 
 of the patient's non-pregnancy. 
 
 It occasionally happens that instead of the ordi- 
 nary menstrual flow, a woman will have a profuse 
 leucorrhceal discharge, and on account of its profuse- 
 ness will seek the advice of a physician. If under 
 such circumstances astringent applications are made 
 use of the patient will be thereby injured. It is usu- 
 ally where the patient is feeble or there is lack of 
 development that such a discharge occurs. 
 
 Derangement of the digestive organs is one of 
 the most frequent accompaniments of this affection. 
 Constipation, as a rule, is always present. The skin 
 indicates the torpid state of the liver and other diges- 
 tive organs. 
 
 The habit of constipation, as well as the condi- 
 tion of the digestive organs, may frequently be im- 
 proved by the administration of casc ara sagrada , or if 
 salines seem to be indicated, the Hunyadi or Fried- 
 erichshalle water is a convenient and efficacious mode 
 of administration. The author has frequently pre- 
 scribed, instead of mineral waters, the following of 
 home manufacture: 
 
 Table salt, i part; bi-carbonate of soda, 3 parts; 
 of which a teaspoonf ul in a full glass of water is taken 
 an hour before breakfast. If taken in hot water in- 
 stead of cold, it frequently proves a decided cathartic. 
 Or a laxative pill may be administered at bedtime. 
 
— 13 — 
 
 The following, which the author has used for many 
 years in habitual constipation, will often be serviceable: 
 
 5 Ext. belladonna, gr. vi. 
 
 Ext. nucis vomicae, gr. xii. 
 
 Ext. colocynth. comp., 3 iss-ijss. 
 M. et divide in pil. No. xxiv 
 Sig. One to be taken at bedtime. 
 
 Scanty and Vicarious Menstruation.— -U nder the 
 head of amenorrhcea attention will also be briefly 
 directed to scanty and vicarious menstruation. The 
 causes of the former are the same as those already 
 mentioned, and it is only of the treatment to which 
 the reader's attention is called. The treatment in the 
 main is similar to that which has already been alluded 
 to. Scanty menstruation is frequently associated with 
 other disorders, of which mention will be made later, 
 as dysmenorrhea, etc. In school girls, in girls em- 
 ployed in shops and in stores there is frequently a 
 scanty flow, although it may appear with regularity. 
 The causes in these cases is either due primarily to 
 non-development or, more frequently, to bad hygiene. 
 In order to treat such girls successfully a careful 
 inquiry is requisite into the habits and daily life of each 
 individual patient. In another class of women who 
 have borne children, but more frequently among those 
 who have aborted, there will be found in the uterus a 
 local cause for the deficient flow. The uterus in such 
 cases is usually large, not necessarily congested, but 
 more frequently enlarged on account of connective 
 
— 14 — 
 
 tissue growth A careful examination frequently shows 
 also atrophy and a contracted condition of the endo- 
 metrium. There is still another class, where the uterus 
 has been congested, the ovaries also congested and 
 enlarged, and afterwards the latter have become 
 atrophied. 
 
 Of the treatment of the first named patients the 
 greatest in importance is hygienic. A routine treat- 
 ment cannot be followed with uniformly good results, 
 as each individual case must be considered by itself. 
 In young girls local treatment should not be instituted 
 unless there is in the opinion of the physician an im- 
 perative demand for it. 
 
 For obvious reasons if an examination of the 
 generative organs of a young girl is deemed necessary 
 it is often best to first anaesthetize her. With such 
 patients a digital examination per rectum is all that is 
 requisite in a great number of instances. Before 
 making such an examination the rectum should be 
 washed out by a copious enema of warm water. The 
 physician can ascertain by a rectal examination as to 
 the development or non-development or the sym- 
 metry or asymmetry of the generative organs. 
 
 In the management of these cases what has 
 already been stated on this point might be repeat- 
 ed. In young girls such as have been spoken 
 of in addition to the hygienic measures referred to 
 everything in the way of constitutional treatment 
 should be of a tonic character. Food is of no service 
 
— f5 — 
 
 unless assimilated, and while patients frequently tell 
 their physicians that they have good appetites and 
 consume large quantities, careful inquiry will often 
 reveal the fact that nutritious food is either not 
 partaken of or else it is not assimilated. To promote 
 the appetite, and at the same time aid in digestion, 
 bitter tonics with mineral acids as heretofore stated 
 will frequently result in improving the general health 
 and increasing the menstrual flow. In scanty flow 
 with these poorly nourished girls the author has fre- 
 quently found Blancard's pills very beneficial in in- 
 creasing the flow and at the same time strengthening 
 them. Quinine, which has no influence in primarily 
 exciting the menstrual flow, if administered after it 
 has begun will almost invariably cause its increase. 
 
 In those who have borne children and the uterus 
 is large from connective tissue growth the application 
 of the iodized phenol to the uterine cavity a few days 
 prior to menstruation, the use of the hot douche, 
 and borated glycerine upon cotton tampons, applied 
 several times a week in the intermenstrual period will 
 have the effect of softening the tissues and stimulat- 
 ing to healthy nutrition. 
 
 In plethoric women and those of sedentary habits 
 some remedy which will tend to stimulate the portal 
 system about a week prior to the time of flow will be 
 found to have a good effect. The vegetable chola- 
 gogues while doing this efficiently, do it more un- 
 
— i6 — 
 
 pleasantly than the mercurials. The following pre- 
 scription has been found serviceable. 
 
 3 Mass. hydrarg. 
 Sodii bicarb., aa gr. iv, 
 
 M. — Divide in pillulas, ii. 
 
 Sig. — Take one at night, the other two nights later, each 
 to be followed by a saline laxative. 
 
 Another mercurial of great service is to take from 
 one to three grains of calomel with three to five or 
 ten grains of bi-carbonate of soda at night to be fol- 
 lowed for two or three mornings with some saline lax- 
 ative, such as the Hunyadi or Friedrichshalle water. 
 Equally good results can be obtained by the proto- 
 iodide of mercury in one-eighth or one-quarter grain 
 doses administered in the same manner as the other 
 mercurials already mentioned, to be followed by sa- 
 line laxatives. If for any reason the physician does 
 not wish to prescribe mercurials, aloin combined with 
 podophyllin will serve an excellent purpose, each pill 
 containing one-eighth of a grain of each of the in- 
 gredients named. Of this combination one or two 
 may be given as a laxative. 
 
 Where systemic abnormalities do not seem to be 
 the origin of the difficulty there is usually to be found 
 a lack of activity on the part of the uterus or ovaries 
 although they may have reached full development and 
 have formerly performed their functions normally. 
 These conditions just mentioned occur the most fre- 
 
— ly — 
 
 quently among women who have passed the meridian 
 of menstrual life and have never borne children. 
 
 Aside from systemic remedies, which tend to in- 
 crease the amount of blood in the pelvis such as iron, 
 quinine, aloes, etc., certain local procedures and medi- 
 cations are also serviceable. Within certain limits 
 stimulating the uterus, acts indirectly upon the ovaries, 
 hence the inactivity of both may sometimes be over- 
 come by the same measures. The simple, daily pass- 
 age of a sound or probe to the fundus uteri for a week 
 or ten days before the regular menstrual date is oc- 
 casionally followed by the desired results. Stimula- 
 ting enemata at the time of the flow may be useful. 
 Of more value, however, than either of these, is the in- 
 fluence exerted by the systematic application of a con- 
 tinuous galvanic current. For this purpose a uterine 
 electrode is passed to the fundus and an ordinary one 
 of sponge placed over the hypogastrium, first over 
 one ovary and then over the other; also over the fun- 
 dus of the uterus. 
 
 Vicarious menstruation occurs in consequence of 
 the entire absence of the normal flow or where men- 
 struation is scanty. Happily, cases are not very com- 
 mon. Vicarious menstruation usually indicates an 
 impoverished condition of the blood and is usually as- 
 sociated with a hemorrhagic diathesis. It is said 
 sometimes to be due to a diseased condition of the 
 blood-vessels themselves. There may be a flow of 
 blood from the nose, throat, gums, breasts, lungs,, 
 
 3 u 
 
stomach, bladder, or from any open wound or ulcer, 
 appearing with regularity at the time the menstrual 
 flow is expected or when there is a disturbance of the 
 circulation in consequence of menstrual suppression. 
 One almost anomalous case came under the author's 
 observation where the menses were suppressed in con- 
 sequence of exposure during a sea voyage, in which 
 there was an oozing of blood through the skin upon 
 the left cheek, lasting for three or four days and re- 
 curring every twenty-eight days. This periodic oozing 
 continued for a period of over two years, normal 
 menstruation never again occurring, when symptoms 
 of phthisis began to manifest themselves, and the girl 
 died in a few weeks. The more common cases, how- 
 ever of vicarious menstruation demand no special 
 treatment unless there is a great loss of blood. Treat- 
 ment should be directed to removing the cause and 
 they should then be treated as cases of amenorrhcea. 
 
 MENORRHAGIA AND METRORRHAGIA. 
 
 Menorrhagia is the term used to designate an ex- 
 cessive loss of blood at the menstrual periods. Met- 
 rorrhagia is the term used to designate a loss of blood 
 from the uterus at other times, it occurring without 
 any reference to periodicity. From the fact that, as a 
 rule, all cases of metrorrhagia are first those of menor- 
 rhagia, the two subjects can be very properly con- 
 sidered together. 
 
 Causes. — The causes of menorrhagia and met- 
 rorrhagia are both constitutional and local. 
 
— 19 — 
 
 Constitutional causes. — Conditions of the system 
 known to have a debilitating tendency are the most 
 prominent. Such affections as the following may be 
 considered as favoring these conditions, viz. : Bright's 
 disease, excessive lactation, chronic diseases of the 
 liver and kidneys, mitral disease, more especially 
 mitral stenosis, phthisis, chronic lead poisoning, 
 chronic constipation, mental depression, malaria, lux- 
 urious living and sedentary habits, residence in a 
 tropical or enervating climate. 
 
 Local causes. — Granular or villous condition of the 
 endometrium, uterine tumors such as fibroids or polypi, 
 subinvolution or enlargement of the uterus from any 
 cause, hypertrophy of the cervix uteri, malignant dis- 
 ease of the uterus, prolapsus uteri, peri-uterine hema- 
 tocele, pelvic cellulitis, laceration of the cervix, uterine 
 displacements, fragments of retained placenta, and 
 ovarian hyperemia come under this head. 
 
 By the majority of physicians and some medical 
 writers the menopause is considered a common cause 
 of uterine hemorrhage, but the author fully endorses 
 the statement of one of his contemporaries (i) that 
 there is very rarely a well marked case of menorrhagia 
 or metrorrhagia occurring at this period of a woman's 
 life unless it be due to " some well marked uterine dis- 
 ease most frequently directly caused by either fungus 
 granulations or cancerous disease." He also heartily 
 
 i. Wylie, American System of Gynecology, Vol. i, p. 417. 
 
20 — 
 
 agrees with this writer in urging upon physicians the 
 importance of this fact and believes with him, " that 
 we would not so frequently see cancer of the cervix 
 advanced to a hopeless stage before an examination is 
 deemed necessary, on account of the erroneous belief 
 that irregular uterine hemorrhage is normal at the 
 menopause." 
 
 Diagnosis. — It is of primary importance in cases 
 of excessive loss of blood from the uterus to ascertain 
 whether it be an abortion or not. If a discharge of 
 blood come on suddenly in a married woman whose 
 age does not forbid the possibility of pregnancy, es- 
 pecially where there has been a lapse of two or three 
 menstrual periods, the physician should strongly suspect 
 an abortion. Of course it would be rash to give an 
 opinion without seeking for further evidences of preg- 
 nancy. In cases of a medico-legal character the im- 
 mediate determination on this point may be impera- 
 tive, but in ordinary practice a little time and patience 
 will serve to determine the question. Excluding 
 abortion from the diagnosis and many of the constitu- 
 tional causes heretofore mentioned, there will be but 
 few cases occurring in practice but what will require a 
 physical examination to determine the cause. It is 
 important for the physician to bear in mind that the 
 disorders under consideration are not in themselves 
 diseases, but rather the symptoms of some constitu- 
 tional or lpcal derangement giving rise to an excessive 
 flow of blood. While we admit that there are cons'ti- 
 
21 
 
 tutional causes, more commonly there is some abnormal 
 or local condition. In case the uterus is not in a 
 perfectly healthy condition some systemic disease 
 may the more easily cause a uterine hemorrhage. 
 Under the head of causes allusion has already been 
 made to acute pelvic inflamation. Now it frequently 
 occurs in pelvic cellulitis or peritonitis, salpingitis and 
 ovaritis that there will be a considerable flow of blood 
 from the uterine cavity which usually affords relief, 
 and should not be checked unless excessive. As a 
 rule, if a woman has menorrhagia and at the same time 
 is suffering from any one of these affections, the men- 
 orrhagia will not manifest itself at the subsequent 
 period if there has been in the meantime complete re- 
 covery from the acute disease. In any of the condi- 
 tions last referred to, before having recourse to any 
 active intra-uterine treatment, the physician should 
 wait until after the occurrence of two or three periods. 
 In cases of menorrhagia or metrorrhagia caused 
 by intra-uterine growths, there is no parallel between 
 the amount of blood lost and the size of the tumor, as 
 it frequently happens that an excessive flow will occur 
 in consequence of a small polypus within the cavity of 
 the uterus. On the other hand there may be a large 
 fibroma existing for quite a long period without there 
 being any excessive hemorrhage so long as the canal 
 of the uterus is not too much encroached upon by the 
 growth. To determine as to a granular or villous 
 condition of the endometrium causing a loss of blood 
 
22 
 
 an examination of the uterine cavity will be requisite; 
 for this purpose the dull wire curette should be used. 
 An examination is necessary in order to determine 
 whether any of the local causes enumerated produce 
 the discharge. Not unfrequently upon examination 
 
 Fig. i. — Thomas' Dull Wire Curette. 
 
 by means of a speculum there will be found to exist 
 laceration of the neck of the uterus associated with 
 glandular and follicular disease; also there may be 
 found to be a laceration with sub-involution of the 
 womb. 
 
 It frequently happens if there is an acute in- 
 flammation of the pelvic organs involving the uterus, 
 that there will be suppression of the menses, and yet 
 later in consequence of this inflammation there will be 
 a vascular condition of the endometrium, or fungosities 
 will be formed, giving rise at first to profuse men- 
 struation and later unless remedied there will be hem- 
 orrhage occurring at irregular periods. Exclusive 
 of cancer and the larger uterine tumors, the inflamma- 
 tory changes just described as occurring within the 
 uterine cavity producing vascularity and fungus 
 granulations, are the most frequent causes in women 
 prior to the age of thirty-five and therefore among 
 the first to be looked for. In women past the age 
 just mentioned without doubt one of the most common 
 
— 23 — 
 causes of metrorrhagia is some form of malignant 
 disease. And just here the author wishes again to 
 impress upon his readers the importance of a physical 
 examination in all cases of uterine hemorrhage oc- 
 curring among women past the meridian of menstrual 
 life; for the reason that there are some cases of epi- 
 thelioma of the cervix and of sarcoma, that can be 
 cured if recognized sufficiently early. 
 
 Fig. 2. — Jenks' Flexible Uterine Sound and Probe. 
 
 In cases where the physician has reason to 
 suspect the presence of intra-uterine growths and at 
 the same time there exists a constricted or tortuous 
 canal, or from any cause a flexible sound or probe 
 fails to determine the diagnosis it may be necessary to 
 dilate the canal for the purpose of further exploration. 
 For this purpose the author prefers rapid, forcible 
 dilatation rather than any form of tent, as being less 
 dangerous, although more painful for a short period of 
 time. 
 
 Treatment. — Of the constitutional causes which 
 have been referred to, if any of them exist, it is im- 
 portant in the outset to pay great attention to the 
 general health of the patient. If the menorrhagia be 
 
— 24 — 
 
 due to general debility, a tonic course of treatment 
 should be instituted, depending in each individual 
 case upon the cause. The author believes that one of 
 the common errors on the part of physicians in such 
 cases is the liberal administration of iron and quinia. 
 The physician cannot frequently resist the temptation 
 where the patient is anaemic apparently from the loss 
 of blood; and yet experience has proven that when 
 a woman has either menorrhagia or metrorrhagia, 
 both iron and quinia will cause uterine congestion and 
 increase the flow of blood. Notwithstanding, both of 
 these remedies are of unquestionable value, at the 
 proper time, but when they are administered to this 
 class of patients they should be given in the inter- 
 menstrual period, or in the absence of hemorrhage. 
 Where the loss has been profuse, the patient should 
 be placed in a recumbent posture with the hips ele- 
 vated. Hemostatics, such as gallic acid or acetate of 
 lead and opium, are sometimes of benefit in diminish- 
 ing the flow, but are not curative. If the uterus is 
 large,with its cavity somewhat dilated, ergot may prove 
 useful. Cannabis indica in quite full doses is sometimes 
 beneficial, more frequently, however, in profuse men- 
 struation, but it is a drug that cannot be universally 
 relied upon. Ergot is also useful where there is chronic 
 hyperaemia and sub-involution. If the uterus is in a 
 relaxed state, or where there are sub-peritoneal 
 fibroids, ergot is but of little use, however, and 
 the same may be said of drugs in general if hem- 
 
— 25 — 
 
 orrhage is due to uterine fungosities, small polypi, or 
 pelvic inflammations. Digitalis is particularly useful 
 if the hemorrhage is due to the forms of organic dis- 
 ease of the heart in which this remedy is indicated. 
 Arsenic is far superior to iron as it improves the gen- 
 eral condition without ever increasing uterine conges- 
 tion, and is of great service in profuse menstruation of 
 early life and at the menopause. It is also valuable if 
 malaria is a factor in the case. Prof. Fordyce Barker ex- 
 tols arsenic highly in the treatment of excessive flow 
 at the time of the menopause where vaso-motor irrita- 
 bility is especially prominent. He believes it exerts 
 a direct influence upon anaemia of vaso-motor origin. 
 In such cases he usually administers full doses of the 
 bromides during the time immediately preceding the 
 flow, and gives arsenic during the inter-menstrual 
 period. 
 
 The bromides of potassium and sodium are valu- 
 able sedatives in ovarian irritation and congestion and 
 thus are beneficial in a profuse flow from these causes. 
 They are also of service in hemorrhage produced by 
 pelvic inflammations. Cathartics often exert a bene- 
 ficial influence if constipation exists. Cathartics, how- 
 ever, are to be avoided if the patient is debilitated, al- 
 though if there is constipation laxatives are at all 
 times admissible. 
 
 Witch hazel is of benefit particularly where the 
 uterus is soft and flabby or the hemorrhage may be 
 considered as of a passive character.* 
 
 * C. D. Palmer, in Trans. American Gyn. Soc, Vol. 12. 
 
— 26 — 
 
 Hydrastis Canandensis has been highly recom- 
 mended by whatever cause the hemorrhage may be 
 produced. Dr. Garrigues praises the gossypium par- 
 ticularly in cases of hemorrhage due to fibroid growths. 
 Dr. Barker combines equal parts of hydrastis cana- 
 densis and the fluid extract of witch hazel, given 
 after the flow has begun. He states than when the 
 hemorrhage is associated with a large flabby uterus 
 and nerve depression he has often found the following 
 prescription very satisfactory: 
 
 1$ Fluid extract of hydrastis, 
 Fluid extract of hamamelis, 
 Fluid extract of Ergot (Squibb's), 
 Tincture of cinnamon bark, aa § i. 
 
 M. Sig. Two teaspoonfuls in a wineglass of water 
 every third hour.* 
 
 The viburnum prunifolium or black haw is a most 
 useful drug in men'orrhagia or metrorrhagia. The 
 author has found it useful in these cases from any 
 cause, while others seem to think it useful only where 
 the hemorrhage is of a passive character. It is par- 
 ticularly valuable, it may be proper to say here, as a 
 uterine sedative in threatened abortion. The most 
 common form of administering viburnum is the fluid 
 extract in half dram to dram doses. The principal ob- 
 jection to this form is its disagreeable taste but that 
 can be disguised in a great measure, by administering 
 it in cinnamon water. 
 
 *Trans. Amer. Gyn. Soc, Vol. 12. 
 
_ 27 _ 
 
 The amount of valerianic acid which the fluid ex- 
 tract contains renders it more of a sedative than the 
 solid extract. Where the disagreeable taste is objec- 
 tionable the solid extract may be given in doses vary- 
 ing from three to eight grains. It is well to begin the 
 use of viburnum in cases of menorrhagia several days 
 preceding the flow and continue its administration 
 through its duration and after its cessation. 
 
 An excellent combination of remedies well adapt- 
 ed for this condition, particularly where an anodyne 
 or sedative is desired, is viburnum, hydrastin and 
 Jamaica dogwood. Parke, Davis & Co. have com- 
 bined the above named remedies with aromatics so 
 as to render them less objectionable to the taste, and 
 designate the preparation as Liquor Sedans. 
 
 Incases where the flow seems to be dependent up- 
 on torpor of the liver much benefit may be derived by 
 the administration of mercurials and saline cathartics. 
 The author's favorite method of prescribing the mercu- 
 rials and salines is as follows: He directs that granules 
 or tablets of the proto-iodide of mercury in one-eighth or 
 one-quarter grain doses shall be taken in the afternoon 
 and evening to be followed the next morning by a sa- 
 line cathartic, his preference being Hunyadi water, al- 
 though seidlitz powders, or citrate of magnesia or 
 other salines, serve the same purpose. It is well to 
 bear in mind, if the physician desires to hasten the 
 action of a saline cathartic, that it can be done by ad- 
 ministering it in a hot solution. 
 
— 28 — 
 
 Where the uterus is large and flabby iron is of 
 great service, but it should be given in the inter- 
 menstrual periods. Some authorities recommend 
 opium in connection with the iron. The remedy 
 which is administered more frequently than any other 
 in uterine hemorrhage is ergot, but unless prescribed 
 intelligently it sometimes may do more harm than 
 good; as for instance, in hemorrhage caused by 
 pelvic inflammation, particularly pelvic cellulitis, in 
 which it will increase the flow as well as the pain. It 
 will also usually increase the hemorrhage if given at 
 the time of the flow, where it occurs in consequence 
 of the uterus being flabby, yet it is beneficial even in 
 these cases, if given in intervals between periods. 
 The author has found that the combination of viburn- 
 um and ergot is of great value. Troublesome cases 
 of this kind are occasionally to be found among school- 
 girls whose nervous systems are taxed to the utmost by 
 what is termed the " forcing system " or " hot-house " 
 style of education, but really is in consequence of an 
 attempt to attain an education while every law of 
 health is violated. 
 
 The most glaring examples of the neglect of some 
 of the most important hygienic laws, thus retarding 
 the development of the generative organs, and laying 
 sure the foundations of chronic invalidism, are to be 
 found in not a few of the fashionable boarding schools 
 for young ladies. This subject cannot here be dis- 
 cussed in extenso, although it is one of paramount 
 
— 2 9 — 
 
 interest not only to parents and guardians, but also to 
 physicians and all those whose thoughts are turned 
 towards the welfare of the coming generation. 
 
 Such girls as above mentioned menstruate irregu- 
 larly and menorrhagia is quite common. As a rule, 
 these girls are constipated, usually obstinately so. 
 This condition induces pelvic congestion and subse- 
 quently menorrhagia, therefore the course to be pur- 
 sued is plainly indicated. The bowels should be 
 evacuated regularly and the patient should be requir- 
 ed to take proper systematic exercise. Hygienic 
 treatment in this class of cases is of paramount im- 
 portance. If an examination is made the uterus will, 
 as a rule, be found flabby. With such patients the 
 author has been able to regulate menstruation where 
 it occurs irregularly by the use of viburnum, generally 
 alone, but sometimes combined with ergot. For the 
 purpose of regulating menstruation where it appears 
 too frequently or irregularly, the viburnum should be 
 administered in the intermenstrual periods beginning 
 a week prior to the expected menstruation, and when 
 the flow appears, if at the right time, the remedy 
 should be discontinued, unless the loss of blood is ex- 
 cessive. 
 
 Dangerous uterine hemorrhages are by no means 
 uncommon demanding prompt and active measures. 
 Where the loss of blood occurs so suddenly and the 
 amount is so great as to threaten the life of the pa- 
 tient, palliative measures are of little avail. These 
 
— 3° — 
 
 emergencies should be met by such means as will 
 promptly check the flow and thus hold it until some 
 curative measures can be instituted. In severe 
 hemorrhage the patient must lie abed with the hips 
 somewhat elevated, cold and acid drinks, cold appli-. 
 cations to the hypogastric and sacral regions, to the 
 vulva and in the vagina are applicable in most cases. 
 In such conditions, some of the remedies already 
 mentioned, are often very serviceable, opium being 
 the most important. Fortunately in these cases of 
 severe hemorrhage, the flow can be arrested with 
 great certainty by mechanical means and topical ap- 
 plications. By mechanical means is meant some form 
 of tampon. If the blood is confined by the tampon it 
 is coagulated and the space between the tampon and 
 the source of the flow is filled with a fibrinous clot, 
 which serves also to close the mouth of the vessels. 
 If the tampon is properly inserted the temporary re- 
 lief is perfect and thus there is afforded valuable time 
 for other modes of treatment. The tampon, if 
 effectual, permits the patient to pass by the danger of 
 the period after which the hyperemia will often sub- 
 side. 
 
 For the purpose of tamponing the vagina the pa- 
 tient should be placed upon her side and a Sims' 
 speculum used, if one is at hand. If the case is urgent 
 and a Sims' speculum cannot be readily procured, the 
 physician can ordinarily retract the perineum suffi- 
 ciently by one or two fingers. The best material to 
 
— 3i — 
 
 be used is sublimated absorbent cotton, rolled up in 
 pieces about the size of an English walnut, each 
 piece being tied with a strong thread for removal. 
 Lamp-wicking is also an excellent material for tam- 
 poning.* A sufficient number of these rolls of cotton 
 to entirely fill the vagina should be inserted. Another 
 method of plugging the vagina has been described by 
 Dr. Thomasf as follows: 
 
 After exposing the neck of the uterus to view 
 in the manner described, " pieces of cotton soaked 
 in water, pressed and flattened out by the fingers, each 
 about the size of a very small biscuit, are pressed into 
 the vaginal cul-de-sac by means of forceps till this is 
 filled. Then other pieces are packed firmly around 
 the cervix until only the os is visible; a smaller pad is 
 then pressed firmly against, or introduced within the 
 cervical canal, and the whole vagina is then filled to 
 its lowest portion." As a rule, after tamponing the 
 vagina a T bandage should be applied. 
 
 It often occurs in severe hemorrhages that the 
 mouth of the uterus is sufficiently open to permit 
 the introduction of some material, such as absorbent 
 cotton saturated with a haemostatic preparation. 
 
 The late Dr. Sims' method of preparing haemos- 
 tatic or styptic cotton for the purpose of tamponing 
 the uterus is simple and admirably efficient. The ma- 
 terial used is the finest quality of cotton wool saturated 
 
 * See Am. Syst. Gynecology, Vol. I, p. 362. 
 
 f Amer. jour, of the Medical Sciences, July, 1876. 
 
— 32 — 
 
 with a liquid composed of one part of the strong solu- 
 tion of the sub-sulphate of iron and two of water. 
 When the cotton is thoroughly saturated it is squeezed 
 as dry as possible and then allowed to become per- 
 fectly dry when it is ready for use. The styptic cot- 
 ton is used after the following manner: Wrap a 
 sufficient quantity of it around a long, small piece of 
 whalebone and then introduce it into the uterine cav- 
 ity, then detach it from the whalebone allowing it to 
 remain. If the flow is comparatively moderate, a 
 single piece of the ironized cotton may be sufficient, 
 but if profuse it will be necessary to put in enough to 
 entirely fill the cavity of the womb. For the purpose 
 of tamponing the uterus with the material just de- 
 scribed, the patient should be placed upon her side 
 and the uterus exposed to view by means of a Sims' 
 speculum. The removal of the ironized cotton is not 
 an easy task if done after the manner described by 
 Sims. The author has been in the habit of wrapping 
 each piece of cotton before its insertion with a piece 
 of strong thread of sufficient length to extrude beyond 
 the vulva. By such means the styptic cotton can be 
 easily removed when its retention is no longer neces- 
 sary. The styptic cotton should not be allowed to 
 remain under any circumstances longer than twenty-four 
 hours, when a fresh quantity can be inserted if there is 
 any demand for it. The author wishes here to record 
 his protest against a practice which has been very 
 common of using styptic intra-uterine injections. As, 
 
— 33 ~ 
 
 • 
 
 aside from the danger, the act itself is liable to pro- 
 due quite a severe shock. Sometimes where the 
 mouth of the uterus and the cavity of the neck are not 
 sufficiently dilated to permit the introduction of 
 styptic cotton into the cavity of the womb, the cervix 
 can be tamponed with carbolized sponge or sublimated 
 cotton; the material being first wrapped with a strong 
 thread to facilitate its removal. The cervical tampon 
 should be removed within twenty-four hours and the 
 vagina thoroughly washed out with some aseptic pre- 
 paration, the best being a solution of bi-chloride of 
 mercury one to three thousand. 
 
 In menorrhagia or metrorrhogia which the physi- 
 cian has reason to believe has been caused by a vil- 
 lous condition of the uterine mucous membrane or so- 
 called fungosities, or from fragments of the products 
 of conception, the means which he uses for a diag- 
 nosis is identical with that employed for cure, viz., 
 the dull wire curette. Before deciding to use the 
 curette an examination should first be made to deter- 
 mine whether the uterus is in a condition for an 
 operation that may be designated as tolerant. If the 
 woman complains of pain - when a digital examina- 
 tion is made it is necessary to decide whether it is 
 caused by a simple hyperesthesia or due to active 
 congestion. If the former, the uterus will tolerate 
 any ordinary operation; if the latter, the simplest 
 operation may prove disastrous. If the uterus or its 
 appendages are tender to the touch in consequence of 
 
 4 v 
 
-34-. 
 
 active congestion the treatment should be palliative, 
 and no active measures or operative procedures should 
 be begun until the active congestion has subsided. 
 This often requires months of judicious treatment. If 
 the uterus be in a tolerant condition and it is decided 
 to use the curette, the canal of the cervix should be first 
 dilated by means of a dilator; Sims's or Ellinger's, or the 
 
 Fig. 4. — Ellinger's Dilator. 
 
 latest device of Molesworth (See Fig. 11) being used for 
 that purpose. Oftentimes the use of the curette is not 
 sufficiently painful to demand the use of an anaesthetic, 
 yet one is required for the more easy management of 
 the patient. The patient can be placed on her side 
 and a Sims's speculum used, or upon her back, as 
 
— 35 — 
 
 the author prefers, and Simon's specula employed. 
 The womb should be held firmly by a vulsellum or 
 strong tenacula and Thomas's dull wire curette should 
 first be used. If the physician finds after passing the 
 Curette over the uterine surface that fragments re- 
 sembling mucous membrane adhere to it, he then pro- 
 ceeds to thoroughly scrape the entire mucous lining. 
 Where fungosities are found to exist within the cavity 
 their location will frequently be confined to one horn; 
 in parous women the one affected having previously 
 been the placental site. The dull wire curette will not 
 always alone suffice, owing to the firmness of these 
 
 'SAX'e'^.'AUH^r/j. 
 
 Fig. 5. — Sims' Curette.. 
 
 growths. It then becomes requisite to use the cut- 
 ting curette of Sims or the scoops of Simon. The 
 curette is useful in other conditions of the uterus 
 causing hemorrhage, for instance, where the entire 
 endometrium is thickened and the uterine cavity 
 dilated. The physician should never promise that 
 
 Fig. 6. — Simons' Scoop. 
 
 a single curetting of the uterine cavity, no matter 
 how thoroughly done, will result in cure. Either the 
 curette may fail to scrape away all the fungus 
 growths or it may ride over those in a formative 
 
- 36 - 
 
 stage, or the causes still continuing to exist which 
 produce intra-uterine fungosities, the operation may 
 be required a number of times before a cure is effect- 
 ed. The author is acquainted with one patient whose 
 uterus was curetted fourteen times before a cure was 
 obtained, but as to the thoroughness of any one of the 
 operations or subsequent treatment prior to the twelfth 
 curetting he has no personal knowledge. Immediately 
 after the curetting is completed the cavity of the uterus 
 should be swabbed with Churchill's tincture of iodine 
 or a tincture of iodine of equal strength. This pre- 
 vents the absorption of septic material and causes the 
 uterus to firmly contract. Subsequently the periodical 
 application of Churchill's tincture of iodine or the 
 iodized phenol will produce an alterative effect upon 
 the endometrium which lessens the liability to the re- 
 turn of fungosities. 
 
 A sub-peritoneal fibroid even of large size may 
 produce no hemorrhage; the nearer a fibroid ap- 
 proaches the mucous lining of the uterus, the greater 
 is the liability to hemorrhage regardless of size. To 
 diminish hemorrhage from sub-mucous fibroids, ergot 
 should be given in the inter-menstrual periods, both 
 for the purpose of checking hemorrhage and hasten- 
 ing their pedunculation. Dilatation of the cervix 
 usually serves a good purpose in lessening hemor- 
 rhage.* Bi-lateral incision of the cervix is effectual, 
 
 *Vide " Dilatation of the Cervix Uteri for the Arrest of 
 Uterine Hemorrhage." By G. H. Lyman. Trans. Amer. 
 Gyn. Soc, vol. 2. 
 
— 37 — 
 
 but forcible and rapid dilatation, is preferable. At 
 the menstrual periods, rest in bed, viburnum, or some 
 of the other remedies already mentioned, should be 
 administered. 
 
 As a means of arresting hemorrhage due to fibro- 
 mata of the uterus, the use of the dull wire curette 
 will often prove efficacious. It has a very warm ad- 
 vocate in Dr. Coe,f the pathologist of the Woman's 
 Hospital in New York. 
 
 The author cannot refrain from giving here the 
 conclusions of Dr. Coe, both as to the cause of the 
 hemorrhage and the modus operandi of its treatment: 
 
 " i. The hemorrhage in cases of fibroid tumors 
 of the uterus has its source not in the tumor itself, but 
 in the hypertroprned endometrium. 
 
 2. The hemorrhage is not directly proportionate 
 to the size of the tumor, but to the extent of the 
 mucous surface. Venous obstruction and the men- 
 strual congestion in the mucosa are the chief active 
 causes. 
 
 3. In certain cases the hemorrhage can be 
 diminished for a considerable period by thoroughly 
 scraping away the hypertrophied endometrium and 
 repeating the operation as often as may be necessary 
 to keep the menorrhagia under control. 
 
 4. Curretting is merely a palliative measure but 
 it may enable the patient to survive until she is re- 
 
 fVide Medical Record, Jan. 28, 1888. 
 
-3»- 
 
 Heved at the menopause, whereas radical operations 
 too often result fatally. 
 
 5. Curetting in these cases should be regarded 
 as an experiment, which, however, is so harmless and 
 frequently successful, that we are justified in giving it 
 a fair trial before advising oophorectomy, miomotomy 
 or super-vaginal amputation. 
 
 6. The use of the curette requires no special 
 skill. It is an operation for the general practitioner, 
 and is much more rational than to allow the patient to 
 become exhausted by repeated hemorrhages which 
 medication and other palliative measures are power- 
 less to control." 
 
 It is almost superfluous to add that as soon as 
 pedunculation has taken place in a submucous or in- 
 terstitial fibroid it should be removed. 
 
 In sub-peritoneal fibroids, ergot frequently does 
 harm instead of good, because it tends to cut off the 
 blood supply from a more or less detachable mass 
 within a closed cavity. 
 
 It is in this class of cases where occasionally con- 
 stitutional and local treatment seems to be of no avail, 
 that the removal of the uterine appendages becomes a 
 necessity. 
 
 In hemorrhage from enlargement or sub-involu- 
 tion of the uterus, or hypertrophy of its neck, the 
 curette is frequently of service. In the inter-menstrual 
 period, the topical use of iodine or the iodized 
 phenol, or iodoform, often prove of great benefit, but 
 
— 39 — 
 
 their application should not be made to the uterine 
 cavity within four or five days of the menstrual date. 
 Iodine should not be employed as an intra-uterine 
 medication more frequently than three times per week, 
 but in the meantime daily applications of iodide of 
 potassium and glycerin (i drachm to the ounce), upon 
 pledgets of cotton will very advantageously supple- 
 ment the use of the iodine. Packing the vagina after 
 the manner first recommended by the late Dr. Talia- 
 ferro, of Georgia, will aid in diminishing the hyper- 
 trophy. In hemorrhage from malignant disease the 
 mildest styptics are to be preferred, since from the ap- 
 plication of powerful remedies there will be greater 
 liability to cause a slough which easily separates and 
 produces a still greater hemorrhage. Glycerite of tan- 
 nin applied upon cotton wool will often suffice. Some- 
 times touching the bleeding points with tinct. ferri 
 chlor. will be beneficial. ' Sometimes a solution or 
 the dry powder of per sulph. iron may be used. In 
 applying the tincture of iron care is to be observed 
 not to touch other tissues than those that bleed. 
 If there is much necrosed tissue, the bleeding can best 
 be checked by scraping as much of it away as possi- 
 ble with a cutting curette. 
 
 In hemorrhage in consequence of prolapsus 
 uteri and other displacements, there is a passive con- 
 gestion caused by obstructed circulation, hence it is 
 necessary to place the uterus as nearly as possible in 
 its normal position by a perfect-fitting pessary, which 
 
— 4© — 
 
 is to be worn through the menstrual period as well as 
 at other times. 
 
 If, in consequence of laceration of the perineum 
 and vaginal walls, there is no support for a pessary, 
 tampons of absorbent cotton or wool rendered aseptic 
 can be worn during the entire inter-menstrual period, 
 being renewed every two or three days and the patient 
 placed in bed during the time of flow. It is advisable, 
 as soon as the patient is in a fit condition, that a sur- 
 gical operation be made for the purpose of restoring 
 the lacerated parts. In hemorrhage from laceration of 
 the cervix the same general directions should be fol- 
 lowed that were last mentioned. Here, too, an 
 operation should be performed as early as the condi- 
 tion of the patient permits. 
 
 It occasionally happens in cases of pelvic hsemat- 
 ocele that the tumor neither disappears by absorption 
 nor suppuration, but remains in a latent condition and 
 then changes take place in its substance. Often in 
 such instances a clear history cannot be obtained, the 
 time of the effusion having been forgotten. When 
 these effusions occur in the retro-uterine space they 
 are sometimes mistaken for retro-version of the uterus, 
 or, in some instances, are called chronic cellulitis. It 
 is in these chronic hematoceles that menorrhagia often 
 manifests itself. 
 
 Where uterine hemorrhage occurs in consequence 
 of this affection, or of pelvic cellulitis, a more intel- 
 ligent treatment can be instituted if a clear history of 
 the case can be obtained. As a rule, pelvic haemato- 
 
— 4 i — 
 
 cele soon disappears by either absorption or suppura- 
 tion. Uterine hemorrhage is more frequent in pelvic 
 cellulitis than in hematocele. In either of these affec- 
 tions if there is an excessive flow of blood from the 
 uterus it is by reason of uterine congestion, the result 
 of an obstructed circulation. The local treatment of 
 these cases should be directed towards obtaining ab- 
 sorption of the exudates. For this purpose iodoform 
 in suppositories either per vaginam or rectum can be 
 advantageously used. Painting the vagina over the 
 swelling with Churchill's tincture of iodine two or 
 three times a week is equally efficacious and more gen- 
 erally preferred on account of the disagreeable odor 
 of iodoform. In the intervals of making these local 
 applications much benefit can be derived by means 
 of tampons of either cotton or wool, but they should 
 not be packed with sufficient firmness for their pres- 
 ence to cause pain. Tampons thus inserted by their 
 pressure exert a very decided influence in promoting 
 absorption. For the purpose of keeping up the con- 
 stant alterative influence of iodine, the tampons or a 
 portion of them should be saturated with iodide of 
 potassium dissolved in glycerine. The free watery 
 discharge which the glycerine causes is also of service 
 for further promoting the absorption of the exudation 
 and diminishing congestion. Copious douches of hot 
 water should be made use of, the patient lying upon 
 her back, or, as recently recommended by Dr. Foster, 
 of New York, in the Sims' position.* 
 
 * Trans. Amer. Gynec. Soc. , 1887. 
 
— 42 — 
 
 It may be proper here to add regarding douches 
 that the patient can be kept dry if a regular douche 
 pan is used. If expense has to be regarded a service- 
 able one of tin can be obtained; if comfort alone is 
 sought in connection with the administration of the 
 douche, a rubber douche pan which can be inflated 
 with air is preferable. 
 
 PAVIDSON RUBBER CO. 
 
 Fig. 7. — Rubber Douche. 
 
 The apparatus known as the Perfection- Douche 
 (Fig. 8) has several qualities conducive to comfort, 
 convenience and utility, one of which is that the foun- 
 tain will give either a continuous stream or, by means 
 of the attached bulb, a forcible intermittent stream. 
 
 Fig. 8. — The Perfection Douche. 
 
— 43 — 
 
 In those cases where menorrhagia occurs as the 
 result of ovarian congestion and chronic enlargement 
 of the ovary, the flow is either irregular or too fre- 
 quent. In this class of cases obstinate constipation 
 is often a cause as well as an accompaniment of 
 ovarian congestion and demands special attention. 
 The author believes that the primal cause of ovarian 
 congestion, enlargement and displacement in very 
 many cases is obstinate constipation. Parents and 
 teachers and all who have young girls in their 
 charge, should be impressed with the importance of 
 the necessity for regularity in this respect, as irrepar- 
 able damage is often effected in this regard in early 
 girlhood. During the inter-menstrual periods ovar- 
 ian irritation can be allayed and the circulation im- 
 proved by the administration of bromides combined 
 with digitalis. 
 
 DYSMENORRHEA. 
 
 Painful or difficult menstruation has in general 
 two sets of causes. 
 
 First constitutional and second local. 
 
 The systemic causes have their origin in either a 
 depraved state of the blood, or an abnormal con- 
 dition of the nervous system. 
 
 The local causes arise from an unnatural form- 
 ation or unhealthy condition of the uterus, ovaries 
 or Fallopian tubes. 
 
 Owing to the fact that it is often extremely 
 
— 44 — 
 
 difficult to distinguish one variety of dysmenor- 
 rhea from another or, in other words, one variety 
 of painful menstruation possesses certain character- 
 istics of some other variety, some writers have 
 deemed it best and less confusing not to classify 
 the different forms of this affection. But dysmen- 
 orrhea is a prominent symptom of a variety of pa- 
 thological conditions, and by classifying the varieties 
 of this disorder it aids the physician in thoroughness 
 of investigation, while a remembrance of them also 
 assists in the instituting of more rational modes of 
 treatment. Therefore the various forms will be classi- 
 fied as follows: 
 
 i. Neuralgic. 
 
 2. Congestive or inflammatory. 
 
 3. Obstructive. 
 
 4. Membranous. 
 
 5. Ovarian. 
 
 NEURALGIC DYSMENORRHEA. 
 
 The first variety is a localized exhibition of a 
 purely systemic condition and accompanied by or al- 
 ternated with the characteristic symptoms of neuralgia 
 in other parts of the body. It is caused by one or 
 more of the following conditions. 
 
 1. Inherited neuralgic tendencies. 
 
 2. Chlorosis. 
 . 3. Anaemia. 
 
— 45 — 
 
 4. Plethora. 
 
 5. Neurasthenia. 
 
 6. Enervating mode of living. 
 
 7. The peculiar blood states of malaria, gout, 
 rheumatism, etc. 
 
 Symptoms and Differentiation. — The pain manifests 
 itself before or after the beginning of menstruation 
 and may cease when the flow becomes established or 
 continue throughout the period. 
 
 Its location when in the pelvis is in the region 
 about the symphysis and down through the lumbar 
 and sacral regions. The pain may be reflected to 
 some other portion of the body even quite remote. 
 Of the distant points the head is perhaps more 
 frequently the seat of pain and it will often be con- 
 fined to one side for twenty-four to forty-eight hours 
 when it will change to the other side, leaving the 
 former comparatively free from discomfort. Occa- 
 sionally it is a finger or a toe in which the pain seems 
 to be concentrated. 
 
 In character it is fixed, sharp and often agonizing 
 in its intensity. When in the uterus, it continues with 
 changing severity, and although it may sometimes ex- 
 hibit sudden sharpness it is never expulsive, as in the 
 case of obstructive and membranous dysmenorrhea. 
 The neuralgic demonstrations which occur during the 
 inter-menstrual period in other parts of the body, 
 especially in the fifth pair of nerves, are present in 
 some patients and absent in others. 
 
- 4 6 - 
 
 The kind of tenderness which is consequent upon 
 severe pain of several hours' duration may mislead at 
 first and cause one to fear the existence of a pelvic 
 peritonitis or other pelvic inflammation, but by care- 
 ful observation the physician will soon be able to put 
 aside any anxieties on that score. 
 
 The febrile symptoms of acute endometritis and 
 the inter-menstrual signs of chronic congestion or 
 hyperplasia of the uterus such as pain, leucorrhcea, 
 and bearing down feelings will be absent. 
 
 CONGESTIVE OR INFLAMMATORY DYSMENORRHEA. 
 
 This form of dysmenorrhcea arises from an un- 
 usual hyperemia of the uterus and peri-uterine tissues 
 which may expand into an active inflammation. In 
 inflammatory cases it is not unusual for the morbid 
 condition to involve both the ovaries and uterus, ex- 
 ceptionally the inflammation may be in the cellular 
 tissue and possibly involve other tissues. 
 
 Causes. — The most common is exposure to cold; 
 mental causes, such as sudden grief, joy, fright, may 
 be super-added to the first named cause. Any of the 
 causes named, where there is an unhealthy con- 
 dition of the uterine tissues or the endometrium, may 
 give rise to either the congestive or inflammatory 
 variety. Uterine displacements, fibroid tumors of the 
 uterus, pelvic cellulitis or peritonitis, or any obstruc- 
 tion to the portal circulation, may be the origin of this 
 disorder. 
 
— 47 — 
 
 Symptoms. — These vary in the onset somewhat, 
 both in time and in severity, according to whether the 
 causes are external influences or conditions within the 
 body. The patient who has previously experienced 
 ho pain at the period may have been suddenly exposed 
 to cold and dampness, or may have received a mental 
 shock after the flow had begun and soon there is a 
 diminution or cessation of the flow flollowed by febrile 
 symptoms, nervousness, and extreme pain in the pelvis 
 and also in the head. On the other hand, without any 
 external cause the patient has a feeling of malaise^ 
 which speedily develops into the above state from 
 four to forty-eight hours before the appearance of 
 the flow. 
 
 In character, the pain is heavy, fixed and some- 
 times accompanied by a rectal or vesical tenesmus and 
 diarrhoea. When the flow has become established, if 
 it is free, the pain diminishes or may cease, but where 
 an inflammation like pelvic cellulitis or endometritis 
 exists the pain may continue throughout the entire 
 period. Where the constitutional disturbances are not 
 marked, the neuralgic and congestive forms of dys- 
 menorrhea are not easily separated. By physical 
 examination one can usually differentiate between 
 congestive and obstructive and ovarian dysmenor- 
 rhea. Occasionally expulsive pains would seem to 
 indicate the presence of some obstruction in the canal 
 which cannot be found on examination. The canal is 
 of normal size, but certain unhealthy conditions of the 
 
— 4 8 - 
 
 endometrium appear to change the character of the 
 blood constituents so that clots are formed within the 
 uterine cavity and are productive of pain in their pass- 
 age. Patients suffering from the forms of dysmenor- 
 rhcea under consideration are usually the subjects of 
 inter-menstrual symptoms of sufficient severity to 
 indicate uterine or ovarian disease. With such per- 
 sons the inter-menstrual symptoms are manifest in the 
 form of painful paroxysms, occurring midway between 
 the periods. These attacks of pain appearing between 
 the times of the monthly flow are frequently very 
 severe. 
 
 OBSTRUCTIVE DYSMENORRHEA. 
 
 Of late years a marked change has taken place 
 among gynecologists in their views concerning the 
 causes of painful menstruation. Formerly the pre- 
 valent belief was that the majority of cases of dys- 
 menorrhcea were due to some obstruction, either con- 
 genital or acquired, within the uterine canal, and more 
 frequently due to uterine flexures than any other cause. 
 When flexion of the uterus is very pronounced it may, 
 to a certain extent, prevent a free flow of blood from 
 the uterus. Clinical experience teaches us, however 
 that there may exist a most pronounced uterine flexure, 
 and yet the patient never suffer from dysmenorrhcea. 
 There is frequently a temporary obstruction of the in- 
 ternal os uteri caused by the swollen condition of the 
 mucous membrane at that point at the period of men- 
 
- 49 — 
 
 struation; there is also, sometimes, a similar condi- 
 tion caused by spasm of the circular fibres surround- 
 ing the os internum at the time of menstruation. But 
 the majority of cases of obstructive dysmenorrhea are 
 to be found in connection with uterine displacements or 
 some deformity of the uterus, either congenital or 
 acquired. Pronounced retro-flexion, where the body 
 of the uterus is crowded down upon the sacrum, is a 
 common cause by reason of the circulation being thus 
 interfered with. A contracted condition of the os ex- 
 ternum, if very pronounced, may cause dysmenorrhcea 
 by obstructing the flow of blood. This condition of 
 the os is sometimes found where patients have pre- 
 viously been treated by caustics, or there exists cica- 
 trization and stenosis of the os externum, from any 
 cause. Congenital contraction of the os externum is 
 usual with a conical and elongated cervix — a condi- 
 tion of things quite common with dysmenorrhceic and 
 sterile women. 
 
 If, by reason of any obstruction, there is retention 
 of the menstrual blood, there will be uterine contrac- 
 tion and pain. Obstruction at the ostium vaginae by 
 preventing a free flow and causing a portion of the 
 blood to be retained within the uterus, may give rise 
 to this form of dysmenorrhcea. 
 
 Symptoms. — The principal symptom of obstructive 
 dysmenorrhcea is severe pain of an expulsive character, 
 and closely resembles the kind of pain which has been 
 designated as uterine colic. The pains usually come 
 
 5 u 
 
— So- 
 on prior to the beginning of the flow and continue 
 until it is well established, after which they gradually 
 subside and the discharge will continue without pain. 
 Byford is of the opinion that in many instances the 
 great congestion accompanying the effort at discharge 
 causing a sort of erection of the uterus, not only over- 
 comes the stenosis but it temporarily, to a great ex- 
 tent, corrects the position or deformity; without this 
 correction the relief would not be complete. 
 
 Diag?wsis. — The diagnosis can only be determined 
 by physical examination. By this means the physician 
 can determine whether there is any obstruction in the 
 vagina in consequence of disease, accident, or some 
 congenital deformity. By examination he can deter- 
 mine also as to the existence of any obstruction in the 
 uterine canal and the cause. 
 
 MEMBRANOUS DYSMENORRHEA. 
 
 By this term we designate the expulsion of a 
 membrane, more or less organized, from the uterus at 
 the menstrual period. From the earliest times up to 
 the present a variety of theories have been set forth as 
 to the pathology and the cause of this symptom which 
 may be called one of the phenomena of menstrual life. 
 This membrane was formerly thought to be the pro- 
 duct of inflammation and was simply a false membrane 
 similar to that formed in diphtheria or membranous 
 croup. Later, Oldham advanced the theory that there 
 was a separation of the mucous membrane or lining of 
 
— 5< — 
 
 the uterus which was expelled with a subsequent men- 
 strual nisus. The cause of this condition was thought 
 to be a peculiar ovarian irritation. 
 
 Virchow has designated this membrane, " the 
 menstrual decidua " and considers that in its forma- 
 tion it resembles the decidua of pregnancy. Simpson 
 regarded its formation as a normal function of the 
 uterus but abnormal in time, circumstances, frequency, 
 and degree. More recently, Dr. John Williams' de- 
 squamative theory as the cause of menstruation if ac- 
 cepted might serve as an explanation for the appear- 
 ance of this membrane. If, on the other hand, Engel- 
 mann's theory of the proliferation and the subsequent 
 exfoliation of the superficial epithelial layer by fatty 
 degeneration be regarded as the true cause of the 
 menstrual flow, then by simply extending a normal 
 process to an abnormal degree, so that fatty degenera- 
 tion takes place rapidly and upon the uterine side of 
 the membrane first, we would have a membrane cast 
 off as a whole or in large fragments instead of the im- 
 perceptible process by which normal menstruation 
 goes on. 
 
 There are numerous other theories which account 
 for the formation of this membrane but in reality there 
 is very little beyond the knowledge of its existence 
 about which we are positive. In appearance there 
 may be large fragments, or it may perfectly represent 
 the shape of the whole interior of the uterus. There 
 are three openings, the external one and one for each 
 
— 5 2 — 
 
 of the Fallopian tubes. Its uterine surface has a rough 
 shreddy appearance and the other is smooth. 
 
 Symptoms. — The pains which accompany the ex- 
 trusion of this membrane are, as one would expect, 
 severe, expulsive, and are often described as colicky 
 pains. Before the membrane has been expelled, the 
 physician may consider the case one of obstructive 
 dysmenorrhcea, but the appearance of the membrane 
 soon makes the diagnosis easy. The patient also 
 suffers from extreme nervousness and hyperesthesia. 
 Sometimes the pain lasts from twenty-four to forty- 
 eight hours. Again, the pain while tolerably severe, 
 is not extreme, neither is it very lasting. After the 
 expulsion of the membrane, there may be a purulent 
 or sanguino-purulent discharge which lasts for several 
 days. 
 
 Differentiation. — There is usually very little trouble 
 differentiating this disorder from other conditions 
 which resemble it. 
 
 OVARIAN DYSMENORRHCEA. 
 
 Some have objected to this term as being a mis- 
 nomer and with some show of reason too, if we admit 
 as many do, that menstruation is a direct function of 
 the uterus, while we know that it does not cause ovula- 
 tion, and further, where the ovaries alone are affected 
 the pain precedes the beginning of the flow and 
 diminishes as the latter continues. However, there is 
 a connection between the two since the hyperemia 
 
— 53 — 
 
 preparatory to the menstrual flow is the cause of the 
 ovarian pain and in the mind of the patient, at least, 
 the two will always be associated together; therefore, 
 although pre-menstrual ovaralgia or a similar term 
 might more definitely express the condition or rather 
 the symptom under consideration, for convenience the 
 old term will here be retained. 
 
 Frequency. — Formerly after neuralgia or the ab- 
 normal blood states had been excluded as causes of 
 pain at the time or preceding menstruation, the uterus 
 was always considered to be the offending organ, and 
 there is no doubt but many a cervix only slightly 
 flexed has been slit up to relieve a dysmenorrhcea 
 which was thought to arise from an obstruction of the 
 canal through this flexure when no real obstruction 
 existed, or if there was one, it was entirely dispropor- 
 tionate to the pain. 
 
 In point of frequency this class should stand next 
 to obstructive and congestive varieties which occur 
 oftenest of all. 
 
 Symptoms: — The nervous phenomena which ac- 
 company this form of dysmenorrhcea are often as 
 startling as the pain is severe. The pain appears from 
 one to five days before the flow and lessens as the lat- 
 ter becomes established. In kind it is dull — a heavy 
 ache — is located in the ovarian regions and is peculi- 
 arly liable to extend down the inside of the thighs. 
 The nervous symptoms vary all the way from a slight 
 nervousness to the well marked forms of hysteria, hys- 
 
— 54 — 
 
 tero-epilepsy and chorea. The amount of pain is 
 usually in an inverse proportion to the quantity of 
 blood lost, and frequently there is an inverse ratio 
 between the severity of the pain and the number and 
 severity of the nervous symptoms. 
 
 Diagnosis: — The symptoms of this form of dys- 
 menorrhcea do not so clearly define the cause that 
 produces them as the obstructive or membranous, and 
 it is often difficult to distinguish it from the congestive 
 variety which has not attained such a degree as to be 
 considered inflammatory. Frequently there has been 
 no sudden cold, severe mental or physical shock, there 
 are no expulsive pains, no marked nervous phenomena, 
 to indicate the existence of uterine congestion, or ob- 
 struction, or ovarian irritation, and only physical ex- 
 amination can decide the cause of the pain. The two 
 first conditions; viz., uterine congestion or obstruction 
 having been excluded, the physician proceeds to in- 
 vestigate by means of, first abdominal palpation, sec- 
 ond, vaginal touch, third, conjoined manipulation. 
 The patient is placed in a semi-prone position and one, 
 or if possible two, fingers are carried up into the pos- 
 terior cul-de-sac. There at the back, or more fre- 
 quently at the left side, a small ovoid body will be felt 
 lying in the lower part of Douglas' pouch. Some- 
 times only an indistinct conception of the shape of 
 this body is to be obtained by the examining finger, 
 but if the other hand press firmly on the hypogastric 
 region it will be brought more closely in contact with 
 
— 55 — 
 the vault of the vagina. Very frequently, however, if 
 the rectum is empty a far more satisfactory examina- 
 tion can be made by it. This body will be found to 
 be an enlarged congested ovary in a state of extreme 
 tenderness. If it can be grasped between the ends of 
 the examining fingers, the pain produced by this pres- 
 sure will be observed by the expression on the patient's 
 face and by other signs, to be that she is suffering ex- 
 quisite. The latter is usually described as producing 
 nausea or sometimes, " it seems to go through her," 
 producing a strange, very uncomfortable sensation in 
 the top of the head. Although this extreme pain ac- 
 companied by nausea is usually considered diagnostic 
 of a congested and an enlarged condition of the ovary, 
 in rare instances one meets with cases in which the 
 tenderness is not excessive, neither is there a nausea- 
 ted feeling produced by pressure although the ovary 
 is congested, enlarged and prolapsed; but the nervous 
 symptoms accompanying this condition are as severe 
 and distressing as in the one previously mentioned. In 
 still other instances the ovary is enlarged but has not 
 become prolapsed, consequently it may be very diffi- 
 cult to reach. Hence, if the examination is not ex- 
 ceedingly thorough one may fail to detect any ab- 
 normal condition. The author would especially im- 
 press upon the mind of the reader the importance of 
 examination per rectum, as by this means, a more 
 thorough knowledge of the true condition can be ac- 
 quired than is attainable by means of vaginal touch 
 alone. 
 
-56- 
 
 Treatment. — So far, the different varieties of dys- 
 menorrhoea have been discussed separately and dis- 
 tinctly, not because denned thus clearly in clinical 
 work, but because we are more easily enabled to show 
 the possible as well as the probable effects as they are 
 related to certain causes. There are well-marked 
 typical forms, but, as a matter of fact, we do not often 
 meet with them. What we do find, is cases in which 
 there is a greater or lesser commingling of two or three 
 varieties. As an illustration: An anaemic neuras- 
 thenic woman may have a retroverted uterus which 
 apparently causes painful menstruation, but in such a 
 case the dysmenorrhea is a combination of causes. 
 The blood is impoverished and its circulation ob- 
 structed, there being several conditions which together 
 may give rise to a neuralgic and congestive dysmen- 
 orrhea. But in each case there is a perceptible and 
 often a marked predominance of the set of symptoms 
 belonging to one variety, a definite conception of 
 which will usually lead us to a discovery of the chief 
 cause; and this should be earliest sought after, for 
 there is no functional disorder requiring more diag- 
 nostic accuracy in order to insure success in treatment, 
 than that of painful menstruation. 
 
 The treatment is both constitutional and local. 
 There is also a variation of methods pursued which is 
 dependent on time, that is to say, the treatment during 
 the menstrual period differs from that of the inter- 
 menstrual period, the former being mostly palliative, 
 while the latter is principally curative. 
 
— 57 — 
 
 Constitutional Treatment. — In the great majority 
 of cases of dysmenorrhoea in young girls, or those 
 under nineteen, painful menstruation is due to a 
 blood dyscrasia, faulty nutrition, or an atonic condi- 
 tion of the nervous system. Consequently constitu- 
 tional treatment alone is required. This is also true 
 of neurotic patients of maturer years. 
 
 It is quite commonly believed that dysmenor- 
 rhoea occurs more frequently among those living in 
 affluent circumstances than among the poor. This 
 belief is in the main correct and yet the severest forms 
 of dysmenorrhoea and uterine and ovarian disorders 
 are seen among over-tasked servants and shop girls. 
 Both classes here alluded to are debilitated in conse- 
 quence of bad hygienic surroundings. 
 
 The author does not agree with some of his con- 
 temporaries who charge intellectual work with being 
 the cause of most of the disorders of the generative 
 organs of young women in particular, of which 
 disorders dysmenorrhoea is the most frequent accom- 
 paniament. It is his belief that there has been a great 
 deal of nonsense written concerning intellectual de- 
 velopment interfering with natural development of the 
 generative organs and the natural performance of 
 their functions. It is not the brain work per se but 
 the lack of proper and sufficient physical exercise, 
 producing thereby a one-sided development which 
 proves injurious. There is not enough muscular 
 activity nor enough fresh air breathed to preserve a 
 
-5«- 
 normal tone of the muscles and digestive organs and 
 an active circulation of the blood, thereby furnishing 
 the conditions under which undeveloped parts con- 
 tinue their growth or developed organs main- 
 tain a healthy condition. The brain needs active, 
 healthy, but not over-taxing work as well as the body. 
 Instead of attributing such disorders as are under 
 consideration to intellectual labor while both mind 
 and body are in process of development, it should 
 rather be attributed to the violation of hygienic laws 
 — another evil among the many benefits of modern 
 civilization. 
 
 Patients, particularly young girls, suffering from 
 dysmenorrhcea are frequently anaemic or chlorotic 
 and possess a nervous organization more than ordi- 
 narily susceptible to external disturbing influences. 
 They need, first of all, when these conditions are pres- 
 ent, a plain but nutritious and digestible diet, 
 regular hours, both as regards eating and sleeping, 
 and as much open air and exercise as they can take 
 without fatigue. Digestion and the condition of the 
 blood are improved by the tincture of the chloride 
 of iron with hydrochloric acid or if the stomach seems 
 intolerant of acid mixtures some of the preparations 
 of the citrate of iron and quinine, or lactate of iron 
 combined with chlorate of potassium. A little later, 
 if there is a neuralgic element present, this course is 
 to be alternated or even combined with the pro- 
 longed use of strychnia or belladonna. Phosphide 
 
— 59 — 
 
 of zinc with nux vomica in pill form is excellent in its 
 effect upon the nervous system. 
 
 In anaemic or chlorotic patients suffering from 
 endometritis or areolar hyperplasia, mercury and 
 arsenic with iron, exert a beneficial influence not only 
 by their primary, alterative and tonic effect upon the 
 general system, but also by a secondary effect upon 
 the diseased uterine mucous membrane and paren- 
 chyma: 
 
 5 Hydrarg. chlor. corros., gr. ij. 
 Liq. arsenici chlor., 3 j. 
 Tr. ferri chlor., 
 Acidi hydro-chlor., aa 3 ij. 
 Syr. simp., % ij. 
 Aquam, ad § vj. 
 
 M. Sig. Dose, one teaspoonful. 
 
 The plethoric patient needs a strict diet and such 
 depletory measures as cathartics, salines being prefer- 
 able, and as there is often a scanty flow, she will be 
 benefited by regularly stimulating the portal circula- 
 tion about a week previously to the period, with one 
 of the mercurial preparations previously mentioned. 
 A saline the following morning may or may not be re- 
 quired. 
 
 In a monograph written for physicians it is un- 
 necessary to any more than allude to the possibility of 
 a neuralgic dysmenorrhea originating in a malarial 
 toxaemia, or the rheumatic or gouty diathesis. Wear- 
 ing flannel to keep the skin warm, baths followed by 
 
— 6o — 
 
 brisk rubbing to increase its activity, and a sojourn in 
 a warm climate during the winter months, have each a 
 certain value. But of all remedies, especially if there 
 is an inherited neuralgic tendency, or there is neuras- 
 thenia, few compare and fewer excel in efficiency 
 that of a sea voyage. All, however, cannot avail 
 themselves of its benefits. 
 
 When there seems to be a lowered tone of the 
 nervous system, nerve tonics may be very advantage- 
 ously supplemented by the use of electricity, a mild 
 galvanic current down the spinal column for ten min- 
 utes and a stronger current through the pelvis or as 
 nearly as possible along the course and about the 
 terminus of the nerve which is the pain conductor. 
 The whole sitting should not exceed twenty-five min- 
 utes, and often fifteen is as long as a nervous patient 
 will bear, especially in the beginning of treatment. 
 
 PALLIATIVE MEASURES. 
 
 As every physician knows by experience, he is 
 frequently not consulted until the patient sends for 
 him to relieve her pain. 
 
 Should the dysmenorrhea be simply an accidental 
 attack due to external causes, then rest in bed, dia- 
 phoretics and sedatives are indicated. The following 
 prescription may be administered: 
 
 B Potassii acetat., 3 ijss. 
 Spts. ether nit., 
 Aquae, aa § J- 
 M. Sig. — Take a teaspoonful every three hours. 
 
— 6i — 
 
 The following sedative suppository will answer a 
 good purpose: 
 
 ]$ Ext. belladonnae, gr. ss. 
 Pulv. assafoetidae, gr. xv. 
 Ol. theobrom., q. s. 
 
 M. et ft suppos. No. iij. 
 
 Sig. — One to be inserted into the rectum once in eight 
 hours while pain continues. 
 
 The following will often be of service in relieving 
 pain: 
 
 ^ Ext. hyoscyami, 
 
 Camphorae, aa gr. x. 
 M. et divide in capsulas No. x. 
 Sig. Take one every hour till relieved. 
 
 The above are especially useful if the pains are 
 spasmodic as well as severe, or the following sup- 
 pository will often relieve pain, unless severe, and is 
 particularly beneficial if there is constipation: 
 
 J$ Ext. stramonii, gr. vi-xii. 
 
 Ol. theobrom., q. s. 
 M. et ft, suppos. No. xii. 
 Sig. Insert one in the rectum every twelve hours. 
 
 These accidental congestions are often the start- 
 ing point of some chronic affection of the uterus more 
 commonly involving the endometrium, therefore, if 
 the constitutional symptoms are marked, the physi- 
 cian should, immediately following such an attack, 
 
— 62 — 
 
 prescribe such a course as will allay irritation and 
 diminish congestion. For this purpose the use of the 
 bromides will be of service and the use of hot douches 
 twice daily should be persevered in so long as needed. 
 In the meantime the bowels should be kept soluble by 
 means of laxatives of which some of the mineral 
 waters, such as Hunyadi or Friedrichschalle are pre- 
 ferable. 
 
 Another palliative remedy is cannabis Indica; 
 twenty-five drops of the tincture or one-half grain of 
 the solid extract may be given every three hours till 
 there is relief. 
 
 It is advantageously combined with assafcetida or 
 hyoscyamus as follows: 
 
 ]£ Ext. cannabis Indicae, gr. j. 
 Ext. hyoscyami, gr. vj. 
 Ext. Valerianae, gr. iij. 
 
 M. et divide in pilulas No. vj. 
 
 Sig. Take one every three hours till relieved. 
 
 Chloral is sometimes useful; ten grains is admin- 
 istered by the stomach or fifteen grains in five or six 
 ounces of warm starch-water every eight hours. 
 
 The anti-spasmodic as well as alterative proper- 
 ties of cimicifuga racemosa and Pulsatilla make them 
 valuable within certain limits in all forms of dysmen- 
 orrhea. 
 
 The cimicifuga should be begun two or three 
 days prior to the beginning of the flow and continued 
 at brief intervals through the entire period. 
 
-63 - 
 
 The following prescription is a convenient form 
 for its use: 
 
 5 Ext. cimicifugae racemos., fl., § iss. 
 
 Elix. taraxici comp., § ijss. 
 M. Sig. Two teaspoonsful every four or six hours. 
 
 The Pulsatilla may be administered simply in 
 water or as follows: 
 
 ]£ Ext, pulsatillae, fl., gtt. xlviij. 
 
 Aquae menth. vir., § ij. 
 M. Sig. Teaspoonful every two hours while pain lasts. 
 
 Apiol has been found especially beneficial in dys- 
 menorrhcea of a neuralgic type, and is useful also in 
 the other varieties of painful menstruation, either with 
 or without a neuralgic element. It is a yellowish, oily 
 substance obtained from parsley and put up for use in 
 capsules, one of which is taken twice a day during the 
 period. Dr. Fordyce Barker holds this remedy in 
 high esteem. 
 
 It has lately been discovered that the new anti- 
 pyretics — antifebrin and antipyrin — are also nerve 
 sedatives of considerable power. While antifebrin is 
 useful in the pains of locomotor ataxia, antipyrin seems 
 likely to prove a specific for neuralgia. Clinical ex- 
 periments have thus far been mostly confined to the 
 various forms of neuralgia affecting the fifth pair and 
 the dorsal, lumbar and sacral nerves, particularly in 
 cases of lumbago and sciatica. In the treatment of 
 dysmenorrhea the author's experience with antipyrin 
 
- 6 4 - 
 
 has as yet been too limited to be able to speak very de- 
 cidedly or dogmatically as to the greatness of its vir- 
 tues. In one case of a young girl suffering from 
 dysmenorrhcea, the effect of half a drachm of 50 per 
 cent, solution of antipyrine administered hypo- 
 dermically was almost instantaneous. The effect is as 
 rapid and as complete as from morphia. Physicians 
 who have used antipyrin quite extensively in painful 
 menstruation speak in high praise of its efficacy. 
 
 From four to eight grains is the ordinary limit of 
 hypodermic doses. In some cases of lumbago and 
 sciatica antipyrin has proved curative as well as pallia- 
 tive. Hence we ought to expect good results from it 
 in neuralgic dysmenorrhcea, especially if the neuralgia 
 gives any evidence of having a rheumatic origin. Our 
 expectations in regard to this remedy as a specific 
 may end in disappointment, but it has already shown 
 an efficacy which should encourage us to continue our 
 experiments. Thirty to fifty grains is given daily, 
 divided in two or three doses, for several weeks. The 
 system does not soon develop a toleration of the drug, 
 but when it does a few days discontinuance serves to 
 enable the remedy to take a fresh hold. In most cases 
 where the neuralgic element predominates, purely sys- 
 temic measures are the most efficacious ones, but oc- 
 casionally local applications produce a revulsive effect 
 upon the peripheral nerves which results in decided 
 benefit. 
 
 Occasionally the administration of an opiate be- 
 
-6 5 - 
 
 comes almost a necessity, but in this quick relief which 
 chloral and opium often afford lies the danger. The 
 same may be said of the other powerful stimu- 
 lants and narcotics. It is well known that many 
 dysmenorrhceics have recourse to them during the 
 menstrual period, and it is in this way that not a few 
 of the alcohol and opium habitues are made. It has 
 been well said: * "These remedies do not cure. They 
 simply add fuel to the flames by inducing a condi- 
 tion of the nervous system — a subjective state of pain 
 exaggerating her own sufferings and seeking relief at 
 any cost — as difficult to overcome as the original dis- 
 ease." 
 
 Local Treatment. — Although many cases of dys- 
 menorrhea from whatever cause can be cured by 
 constitutional means alone, the fact, nevertheless, re- 
 mains that there are local conditions which can be 
 remedied only by having' recourse to local treatment. 
 The local conditions heretofore mentioned as causing 
 dysmenorrhea will not be considered seriatim strictly, 
 but the order in which they have been mentioned will 
 be adhered to with as much precision as is deemed 
 advisable for a practical consideration of the subject. 
 
 In unhealthy conditions of the uterine paren- 
 chyma or the endometrium, and in some cases where 
 there is hyperesthesia at or about the internal os, as 
 
 *C. D. Palmer, Trans. Am. Gyn. Soc, Vol. viii., Art. 
 Dysmenorrhea. 
 
 6 u 
 
— 66 — 
 
 well as in some instances where there is a lack of de- 
 velopment of the entire organ, the passage of a sound 
 to the fundus several times a week previous to the 
 menstrual period will often be of great benefit; this is 
 particularly beneficial in overcoming the hyperesthesia 
 of the uterine canal at the os interum. In cases 
 where an active congestion of the uterus exists, caus- 
 ing tenderness and particularly if it seems to be 
 less movable than is normal, local treatment 
 to the uterine cavity should not be undertaken. In 
 such a case, in addition to the constitutional measures 
 which have been mentioned, local treatment should 
 consist of hot douches and such applications within 
 the vagina as will cause the absorption of any of the 
 products of congestion or inflammation and improve 
 the circulation of the blood within the pelvic organs. 
 
 In many instances the only local application 
 necessary for bringing about the desired condition in 
 addition to the douches is the insertion of tampons of 
 cotton or wool saturated with glycerine and boro- 
 glycerine. Frequently the thorough dusting with 
 boracic acid of tampons already saturated with pure 
 glycerine will suffice. The use of boracic acid upon 
 vaginal tampons where they are liable to remain for 
 any length of time is of great service in preventing 
 fermentation of the glycerine and decomposition of 
 the secretions, which otherwise is liable to occur. Ap- 
 plications such as have just been described should be 
 made every alternate day or three times a week, and 
 
-6 7 — 
 
 the hot douche should immediately follow the removal 
 of the tampons. 
 
 This treatment will produce, while the tampons 
 are in situ, a profuse watery discharge from the vagina, 
 thereby relieving the over-distended vessels, and also 
 cause the tenderness to disappear. Not unfrequently 
 where there are quite firm peritoneal adhesions ren- 
 dering the uterus immovable and giving rise to pain 
 and tenderness, the plan of treatment just described 
 will be efficacious in causing the symptoms just 
 enumerated to subside within a few weeks. 
 
 In the class of cases just described, before intra- 
 uterine treatment of any kind is instituted there 
 should cease to exist any indication of circum-uterine 
 inflammation or congestion. This being effected, fur- 
 ther examination may be requisite; as, for instance, 
 there may be leucorrhoea with granular erosion about 
 the external os, and if a sound or probe is passed into 
 the uterine canal, there will usually be found a pro- 
 nounced hyperesthesia at the os internum. In some 
 of these cases, there is neither a flexure or a 
 growth by which the lumen of the canal is encroached 
 upon nor, in fact, does its calibre seem to be dimin- 
 ished, yet there are symptoms of obstruction. The 
 pains are spasmodic, although not really expulsive. 
 In such cases there usually exists an increase of 
 tissue somewhat indurated in character around the 
 os internum, extending in the form of an inverted 
 cone down the cervical canal especially on the 
 
— 68 — 
 
 anterior wall. The nerves supplying the canal around 
 the os internum are enclosed and pressed upon by 
 this hardened tissue and the fluxion consequent upon 
 the menstrual nisus increases the pressure to a degree 
 which results in severe pain. In other cases of dys- 
 menorrhcea, for which the same treatment, that remains 
 to be described, is applicable, the uterus is not fully 
 developed; its neck is pointed and indurated, with 
 frequently one lip longer than the other, and there is 
 often an anteflexion of its body. In such uteri, if a 
 sound or probe is passed into the canal, there is, as a 
 rule, hyperesthesia at the os internum the same in 
 character as in uteri that are enlarged. 
 
 In both classes above mentioned, to relieve pres- 
 sure and diminish hyperesthesia an excellent result is 
 obtained by forcible dilatation; this is partially due to 
 the revulsive effect of stretching over-sensitive nerves 
 and partially to producing absorption of indurated tis- 
 sue and thereby liberating confined nervules. For 
 this purpose, the Sims or Ellinger dilator with diverg- 
 ing branches, or Peaslee's (Fig. 9), (for slight dila- 
 tation), or Hank's dilators with their various sized 
 bulbs may be employed. 
 
 The dilatation can frequently be made without 
 the aid of an anaesthetic, but in some cases the region 
 about the os internum possesses such an hyperesthesia 
 as to necessitate its use. Occasionally an anesthetic 
 is required on account of the nervousness or timidity 
 of patients. 
 
-6 9 - 
 
 For the purpose of dilating, the patient should be 
 placed in either Sims' or Simon's position. In the 
 former, Sims' speculum is introduced, while in the 
 latter Simon's instrument is used. The patient being 
 placed in position, the vagina should be thoroughly- 
 wiped out with some aseptic preparation, such as a 
 solution of bi-chloride of mercury one to three 
 thousand, or carbolic acid one to forty. All instru- 
 ments should be first thoroughly clean, and in hos- 
 
 Fig. 9. — Peaslee's Dilator. 
 
 pital or dispensary practice more especially it is ad- 
 visable that they be kept in carbolized water or in 
 alcohol, the latter being the author's preference. In 
 either position the cervix should be held firmly by 
 means of a vulsellum or a double tenaculum. If the 
 Hank's dilator is employed the smallest size is in- 
 troduced first and allowed to remain until the pain 
 from the dilatation 'at the os inernum has nearly 
 passed away. The next size larger is then inserted. 
 
— 7© — 
 
 Three sizes are usually sufficient and frequently the 
 smallest size suffices for the first dilation. If a Sims' 
 or Ellinger's dilator or one of similar style is to be used 
 it may first be of service to pass a uterine sound to the 
 fundus for the purpose of facilitating the use of the 
 
 Fig. io. — Hank's Dilator. 
 
 dilator. And yet, very often the dilator can be passed 
 as easily as a sound. In using any of the dilators 
 mentioned care should be exercised lest the points of 
 the blades injure the mucous membrane of the fund- 
 us. In inserting the dilator the instrument should 
 be allowed to ascend with the uterus as far as the lat- 
 ter 's attachments will allow for the purpose of pre- 
 venting the slipping out of the blades when they are 
 separated. For this purpose also the vulsellum or 
 tenaculum should hold the uterus as firmly as possible. 
 As soon as dilatation begins the physician should 
 carefully watch the behaviour of the instrument that 
 he may regulate the dilatation. The amount of physi- 
 cal power required to effect the requisite amount 
 of dilatation must of necessity vary considerably. In 
 undeveloped uteri but little force is requisite while in 
 
— 71 — 
 
 other cases where there is considerable hyperplasia 
 much more is required. 
 
 Ordinarily the blades of the dilator require to be 
 separated about one-third of an inch. The Ellinger's 
 dilator improved by Goodell, has a scale in the handle 
 by which means the operator can tell with precision 
 the distance the blades are separated. After dilata- 
 
 Fig. ii. — Molesworth's Dilator and Intra-uterine 
 
 Syringe. 
 
 tion has been effected the endometrium of the body 
 should be anaesthetized by the local application of 
 carbolic acid. This is done* by wrapping an applica- 
 tor with cotton which is saturated with carbolic acid 
 and then squeezed quite dry to prevent the applica- 
 tion of an excess of the acid. This can be very neatly 
 accomplished by using a cervical protector. The 
 author frequently uses for the same purpose and in a 
 similar manner the iodized phenol thus obtaining the 
 
 *The three middle figures of the cut (No. n) represent 
 the dilator; the top and bottom figures are a device for intra- 
 uterine applications. 
 
— 72 — 
 
 anaesthetic properties of the carbolic acid and the 
 antiseptic and alterative properties of iodine. If the 
 endometrium is very sensitive carbolic acid alone is 
 probably the best application. But in undeveloped 
 uteri, if not sensitive, the saturated tincture of iodine 
 may be applied on account of its stimulating effects 
 and thereby aiding in the further development of the 
 uterus. 
 
 Just prior to removing the vaginal speculum 
 a few grains of iodoform may with propriety be 
 dusted about the cervix. After dilatation the patient 
 is then placed in bed where she remains for a few 
 days. If the pain does not pass away within a short 
 time an anodyne should be administered. The author 
 wishes to say here, en passant, that it is his firm belief, 
 based upon many years of experience and observa- 
 tion, that patients thrive and recover much quicker 
 from surgical operations, whether minor or major, 
 without the administration of opiates. 
 
 In patients who have -been under treatment long 
 enough for the physician to become acquainted with 
 the amount of tolerance to interference which the 
 uterus possesses, he may sometimes feel justified in 
 making dilatation in his office, but unless his experi- 
 ence with his method and with his patient has been 
 extensive enough to give him a feeling of surety and 
 safety upon this point he should not attempt it. The 
 prudent physician will usually insist upon making at 
 least the first dilatation at the patient's home. There is 
 
— 73 — 
 
 another point which the author deems of the greatest 
 importance, as bearing upon not only this operation, 
 but all operations within or about the uterus, viz.: 
 that before any procedure is contemplated the physi- 
 cian should thoroughly examine the retro-uterine 
 space for the purpose of ascertaining if there has been 
 any previous inflammation about the uterus or in the 
 uterine adnexa. For this purpose a simple vaginal 
 examination will not suffice. A digital examination 
 should be made per rectum, it being previously washed 
 out by an enema, nor should the physician be satisfied 
 with a vaginal examination with the patient in the 
 dorsal position. The patient should be placed in a 
 semi-prone position, making no special difference 
 whether on the right or left side, that being a matter 
 of convenience. A distended Fallopian tube or an en- 
 larged ovary may be unsuspected, or a previous pelvic 
 inflammation, which has been so slight as not to have 
 been considered by the patient, may exist notwith- 
 standing. Should either the first or the last conditions 
 be present a forcible dilatation of the cervix, though 
 comparatively safe at other times, might now be the 
 lighted match placed beneath the waiting tinder. 
 
 Usually a period of from seven to ten days should 
 intervene before another dilatation. Sometimes as 
 many as three dilatations can be made with safety be- 
 tween the menstrual periods. If there chances to be 
 along-standing disease of the endometrium, dilatation 
 may be required a number of times before any signs 
 
— 74 — 
 
 of improvement are manifest. The improvement of 
 the patient will depend largely upon the state of her 
 health. 
 
 In case there are any complications particularly 
 of an acute character, like vaginitis, acute catarrh of 
 the endometrium, or any localized pelvic inflammation, 
 they should first be treated to a successful termination 
 before having recourse to dilatation, which might 
 speedily light anew the inflammation. 
 
 If dilatation has the desired effect the physician 
 will usually observe, with the exception of undeveloped 
 uteri, that the neck presents a shortened appearance 
 and the axis of the canal assumes its normal direction, 
 while the secretions of the cervical glands will present 
 a transparent appearance instead of a yellow, opaque 
 appearance of disease. In case the treatment is 
 effectual, a uterine probe can be passed without elicit- 
 ing any signs of pain. 
 
 Dysmenorrhea, in consequence of displacement of 
 the uterus, is of frequent occurrence. Among women 
 who have not borne children the most common dis- 
 placements are ante-flexions or ante-versions. It is 
 possible that the caliber of the uterine canal may be 
 diminished at the point of flexion, but if that is the 
 case, it is not necessary to have recourse to a surgical 
 operation with a hysterotome or other cutting instru- 
 ment, has been practiced so extensively in the past. If 
 there is a uterine flexion above the internal os there 
 will be painful menstruation. Clinical observation 
 
— 75 — 
 
 has taught that, usually, the above named symptom 
 is not manifested if the flexion is at the juncture of 
 the neck and body; the cervix in these cases being 
 thin and long, sometimes bent quite acutely, and al- 
 though such women are usually sterile, they do not 
 on account of this condition of the uterus always suf- 
 fer from painful menstruation. 
 
 There is generally in women with uterine flexion 
 above the neck, a condition of health much below par 
 the difficulty having its starting point at the beginning 
 of menstrual life, consequently, the physician's prog- 
 nosis cannot be as favorable as it would be in dysmen- 
 orrhea from other causes. The first indication is to 
 straighten the uterine canal and maintain the body of 
 the uterus in its normal position. The many surgical 
 procedures which have been devised for such cases 
 will not be here discussed. The author will simply 
 state what he considers is the best course to be pur- 
 sued in each case. In many instances, the flexion can 
 be overcome by forcible dilatation. The treatment of 
 uterine flexions does not come strictly within the pro- 
 vince of this paper; and yet, in considering painful 
 menstruation associated with, or depending upon them, 
 it is not out of place to mention some of the means 
 of cure. The author is not in favor of cutting opera- 
 tions except in certain forms of congenital or acquired 
 atresia of the uterine canal. In a very few cases, more 
 particularly where there is lack of development, the 
 intra-uterine stem pessary may prove of service, and 
 
- 76- 
 
 yet in all probability a better mode of treatment in 
 deficient development of the uterus, either with or 
 without flexion, is first forcible, rapid dilatation to be 
 followed by local stimulating applications and gal- 
 vanism. 
 
 In dysmenorrhea with ante-version of the uterus 
 the pain is doubtless due to obstruction of the circula- 
 tion of the blood instead of any diminution of the 
 calibre in the uterine canal — it really being a form of 
 congestive dysmenorrhea. In chronic cases the ad- 
 justment of the pessary which maintains the uterus in 
 its normal position, thus permitting an unobstructed 
 circulation, is without question the proper treatment. 
 Many times one of the Emmet or Albert Smith pes- 
 saries, or some of their modified forms, if perfectly 
 fitted, will suffice. But on the other hand, oftentimes 
 some other variety of pessary particularly adapted for 
 forward displacements of the uterus will be required, 
 one of the best being Gehrung's ante-version pessary. 
 
 In painful menstruation with retro-version and 
 prolapse of the uterus the pain is also generally in 
 consequence of an obstructed circulation. If there 
 exists a general pelvic congestion to which is added 
 the menstrual fluxion, there is often pain in the uterus 
 and one or both ovaries. In such instances, in addi- 
 tion to pursuing the general plan of treatment which 
 has already been alluded to, it usually becomes 
 requisite, before a cure, or even relief can be obtained, 
 to adjust a pessary that fits and retains the uterus in 
 
— 77 — 
 its normal position. Patients frequently say that they 
 cannot wear any kind of pessary, having attempted it 
 many times. Sometimes this may be the fault of the 
 physician for nothing is truer than that the physician 
 who has mastered the art of fitting pessaries perfectly 
 has mastered the most difficult part of the mechanics 
 of gynecology. 
 
 Where dysmenorrhcea seems to be caused by the 
 existence of uterine fibroids or polypi, the treatment 
 must depend upon the condition induced by the ad- 
 ventitious growths. If there is obstruction from 
 fibroids, dilatation will usually be of benefit. If any 
 form of intra-uterine growths of small size cause pain- 
 ful menstruation they should be removed if it can be 
 done by ordinarily safe methods. 
 
 Occasionally cases of dysmenorrhcea are met 
 with, in consequence of partial vaginal atresia. This 
 abnormality may be congenital or the result of some 
 form of disease, not infrequently syphilis. This con- 
 dition may be treated by dilatation by means of tents 
 or, what is better, bougies of graded sizes or, in some 
 instances, by incising the obstruction. If there is an 
 unmistakable syphilitic taint, constitutional treatment 
 will be demanded as well. Occasionally painful men- 
 struation is caused by an imperforate hymen in which 
 event the hymen should be incised, but extreme cau- 
 tion is requisite on the part of the physician, particu- 
 larly if there is much accumulation of the menstrual 
 fluid. The best plan is to aspirate, the fluid before 
 
- 7 8- 
 
 incising the membrane for fear that the moment the 
 atmosphere comes in contact with the uterus contrac- 
 tion will be excited and by a sort of regurgitation the 
 menstrual fluid will be forced through the Fallopian 
 tubes, which under such circumstances are usually 
 dilated. This is, undoubtedly, the reason of fatal 
 results ensuing after the simple incising of the hymen. 
 
 Membranous Dysmenorrhea. — There is so little 
 unanimity of opinion concerning the true origin of 
 membranous dysmenorrhea and so little exact knowl- 
 edge of its causes that we have but a small and un- 
 stable foundation upon which to base treatment. 
 Patients suffering from this disorder are frequently 
 neurotic and are in a debilitated condition as regards 
 the general system. Therefore, the general treat- 
 ment mentioned under the head of constitutional 
 treatment would be indicated. Alterative applica- 
 tions to the endometrium, such as Churchill's tincture 
 of iodine or the iodized phenol, seems at times to 
 render service. 
 
 In some of these cases of membranous dysmenor- 
 rhea the symptoms are aggravated by being com- 
 plicated with other uterine disorders. The dysmen- 
 orrhea will at least be ameliorated if not cured by 
 proper treatment of these affections. 
 
 As palliatives, it sometimes becomes necessary to 
 relieve the patient from her extreme suffering by 
 means of subcutaneous injections of morphine. But 
 this mode of treatment is quite objectionable for 
 
— 79 — 
 reasons given elsewhere. Byford* recommends 
 forcible dilatation of the cervix to facilitate the ex- 
 pulsion of the membrane and thereby shorten the at- 
 tack. 
 
 There are some patients with this disorder in 
 whom the monthly suffering is so severe, and the conse- 
 quent neurasthenia and general debility so extreme 
 it would seem advisable to bring about a premature 
 cessation of the menses by removal of the uterine ap- 
 pendages. 
 
 EXTRA-UTERINE PELVIC ENLARGEMENTS AND EX- 
 UDATIONS. 
 
 Under this head will briefly be considered the 
 pain which precedes or accompanies menstruation 
 where there is ovarian congestion, enlargement or pro- 
 lapse, inflammation of the adjacent tissues, such as the 
 cellular tissue, lymphatics, or Fallopian tubes. 
 
 In all these there is more or less obstructed circu- 
 lation and when the menstrual fluxion is super-im- 
 posed the tension becomes so great that pain results. 
 With the majority the pain diminishes or ceases when 
 the flow becomes established; but in plethoric patients 
 with congested, enlarged or prolapsed ovaries, who 
 have a scanty discharge, there is no excess of pain till 
 two or three days after the beginning of the flow. In 
 these cases the amount of blood lost is not in propor- 
 
 Vide, Byford, p. 152. 
 
— 80 — 
 
 tion to the amount of its increase incidental to the 
 menstrual nisus, and congestion is therefore rendered 
 greater instead of being diminished as the flow con- 
 tinues. In patients suffering from extra-uterine pelvic 
 disorders there is every variation in the degree of men- 
 strual pain. Some experience so little additional dis- 
 comfort at that time that they cannot be regarded as be 
 ingatall dysmenorrhceic; while others pass from one to 
 three days in pain which at times, amounts to anguish. 
 These will usually be found to be neurotic patients in 
 whom pain is largely subjective. There is no doubt 
 however, that in some cases there is a proliferation of 
 nerve tissue within the exudate, or an abnormal ex- 
 tension of the terminal nerve fibers about the increased 
 number of vesicles in an enlarged ovary, which occurs 
 to a greater extent in some than in others. This 
 would account partially for the variation of pain in 
 different cases of apparently equal gravity. In all of 
 these, there is evidently peripheral irritation, which is 
 the chief indication for the use of the bromides, and 
 of these the bromide of sodium is preferable to the 
 bromide of potassium, being more acceptable to the 
 taste and to the stomach, besides it is less liable to 
 cause cutaneous eruptions if taken a long time. 
 
 ~fy Sodii brom., 3 xss, 
 Aquae, § iv. 
 
 M. Sig. — Take a teaspoonful three or four times a day. 
 This should be done five or six days before the 
 
— 8i — 
 
 expected time of the flow and continued for a day or 
 two after its cessation. 
 
 Aside from the treatment already mentioned, 
 which is directed towards improving the general sys- 
 tem, an alterative course is also required, and to meet 
 this indication, one of the following combinations will 
 be serviceable: 
 
 3 Hydrarg. chloridi corros., gr. ss-j. 
 Potassi chloridi, 3 iij-v. 
 Glycerinae, § j. 
 Aquae, § iij. 
 
 M. Sig. — Teaspoonful three or four times a day. 
 
 The bichoride may also be advantageously com- 
 bined with the iodide of potassium even in cases 
 where there is no specific taint. 
 
 In the local treatment of dysmenorrhea due to 
 pelvic exudations, or displaced and enlarged ovaries 
 and tubes, there is many times an opportunity for the 
 exercise of that virtue designated as patience on the 
 part of all concerned before any indication of an im- 
 provement is perceptible. It has seemed to the author 
 as if there was no class of patients coming under the 
 care of physicians with whom proper treatment can 
 often be faithfully and systematically conducted for SO' 
 long a period of time without results being apparent 
 to the patient, as in those affected with the variety Of 
 disorders under immediate consideration. 
 
 The first indication of treatment is to quiet local 
 
 7 u 
 
— 82 — 
 
 irritation, for which purpose can be used with good 
 effect hot vaginal douches and sitz baths. 
 
 For the purpose of avoiding any repetition of 
 what has already been stated concerning treatment, 
 many matters pertaining to it which might appropri- 
 ately be alluded to here will be omitted, but the author 
 desires, however, to have his readers bear in mind that 
 the same general principles of constitutional and local 
 treatment heretofore alluded to should be carried on 
 if pathological conditions exist analogous to those al- 
 ready described; as, for instance, if there is congestion 
 of the uterus in consequence of the existence of the 
 remains of a pelvic cellulitis, seeming to cause dys- 
 menorrhea, it is to be treated in a similar manner to 
 that previously mentioned. 
 
 If with a dysmenorrhceic there is discovered a 
 mass of inflammatory deposit and, as is of frequent 
 occurrence in such cases, the uterus is retroverted and 
 bound down by firm adhesions, or there is, or is not, 
 in addition some enlarged lymphatic glands to be felt 
 within the vagina, or a swollen sensitive Fallopian 
 tube, or an enlarged and tender ovary to be felt, the 
 physician should be extremely cautious about institu- 
 ting any form of intra-uterine treatment. In such 
 conditions, first is required the local treatment lately 
 mentioned, viz., douches, baths, etc., to be followed 
 by painting within the vagina the mucous surface 
 overlying the enlarged parts with Churchill's tincture 
 of iodine, or what is termed the saturated tincture of 
 
- 8 3 - 
 
 iodine, the formula of which is given on page 8. 
 While the douches and baths can be made use of once 
 or twice daily, the iodine cannot be applied so fre- 
 quently. It can often be done every alternate day or 
 certainly twice or three times each week. To do this 
 the most effectually, the patient should lie in a semi- 
 prone position and a Sims's speculum be employed, or 
 if no assistant is attainable the speculum recently de- 
 vised by Darrow can be used. 
 
 Fig. 12. — Darrow's Self- retaining Speculum. 
 
 Another remedy of great service in promoting 
 the absorption of inflammatory deposits is iodoform. 
 
— 8 4 — 
 
 This can be placed in the vagina by means of an in- 
 sufflator, or it can be placed upon cotton or wool 
 tampons, or even a better way of using it is in the 
 form of suppositories within the rectum. 
 
 Following the topical applications above alluded 
 to it is the author's usual practice to pack the vagina 
 with cotton or wool tampons to which borated glycer- 
 ine has been added. In some instances where the 
 weight of the tampons thus saturated causes pain, or 
 by reason of their weight they will not remain in posi- 
 tion, dry tampons of cotton or wool thoroughly im- 
 pregnated with boric acid may be inserted. Tampons 
 thus used, serve a manifold purpose, viz., they answer 
 as a medium of medication and by their pressure les- 
 sen congestion, promote absorption of exudates and 
 adhesions, destroy hyperplastic tissue, lessen hyperes- 
 thesia, and rectify displacements. If inflammation is 
 acute or sub-acute, hot water is the remedy /#/- excel- 
 lence, but later when the case has become somewnat 
 chronic, hot water, while still of great service, becomes 
 only supplementary to other measures, and treatment 
 by pressure with tampons is pre-eminently the most 
 efficacious. 
 
 The author is convinced from clinical observation 
 that displacement and congestion of the ovaries is a 
 common factor in causing much of the pain and dis- 
 comfort of dysmenorrhea. In some instances being 
 the sole cause. Associated with these conditions are 
 frequently found enlarged and prolapsed Fallopian 
 
- 8 5 - 
 
 tubes. In treating these conditions the physician 
 should aim first, to diminish congestion with its attend- 
 ant sensitiveness, and after these symptoms are rem- 
 edied he should attempt the restoration of the ovary 
 to its normal position. For this purpose, the patient 
 should be placed in the knee-chest position and after 
 the ovary is pushed as high as its tenderness will per- 
 mit by means of one or two fingers within the vagina, 
 it should be retained in position by means of tampons 
 of cotton or wool while the patient occupies the same 
 posture. In many instances where the ovary is pro- 
 lapsed and is not held down by adhesions, the pressure 
 of the atmosphere, if the perineum is retracted will 
 often cause it to assume its normal location after which 
 it should be retained there by the tampons. Some- 
 times the physician will feel at the left of the uterus 
 what he believes to be a prolapsed ovary or Fal- 
 lopian tube, but if it is not particularly tender while 
 being pressed upon and feels similar to a varicocele 
 in the male, he can rest assured that it is neither one 
 nor the other, but instead, it is a varicose condition 
 of the pampinniform plexus usually brought on by 
 habitual constipation and for that reason to be 
 found more frequently upon the left side. 
 
 Where there is great tenderness within the vagina 
 of any of the organs, the author uses for tampons very 
 small pieces of cotton or wool to which threads are at- 
 tached for their removal, but for the purpose of in- 
 citing pressure and aiding in support of the organs he 
 
— 86 — 
 
 has adopted a method of placing them differently 
 from the ordinary method of simply filling the vagina 
 with a mass of cotton or wool. He has them made 
 in the form of quite firm cylinders from two to 
 three inches long and one-half of an inch in diameter. 
 A Sims' speculum having been introduced the first 
 tampon is placed in the retro -uterine space, the next 
 two on either side of the cervix and a fourth in front. 
 The first and fourth lie transversely in the vagina 
 and the second and third nearly so, the four form- 
 ing a trapezoid with the longest side back and the 
 shortest in front. Sometimes a soft pledget is 
 placed in the posterior cul-de-sac before the first 
 hard tampon is inserted. 
 
 If these four or five do not sufficiently fill the 
 upper half of the vagina others may be lodged be- 
 low them either observing the order of the first 
 four or simply laying them crosswise with their 
 length corresponding to the transverse diameter of 
 the pelvis. 
 
 If the tampons are not packed so firmly as to 
 cause pain, their presence will actually conduce to 
 the patient's comfort, especially if there is any ac- 
 companying uterine displacement. 
 
 In many cases of dysmenorrhea the ovaries and 
 Fallopian tubes cannot alone be felt by vaginal ex- 
 amination, but are felt to be immovable and bound 
 firmly down by reason of adhesions, as has been previ- 
 ously alluded to. This condition of things is here 
 
— 87 — 
 
 mentioned for the purpose of directing attention to 
 still another mode of treatment, a mode which is ap- 
 parently attaining very great prominence in the do- 
 main of gynecology; namely, electricity. The success 
 
 Fig. 13. — Front View of Tampons when in Position. 
 Patient in either Knee Elbow or Sims' Posture. 
 
 which has been attained by this agent in other depart- 
 ments of medicine and surgery lead us to hope that 
 
— 88 — 
 
 like good results may be obtained in the class under 
 consideration. In the department of rhinology and 
 laryngology it is not the galvano-cautery alone that is 
 used for removing adhesions and disposing of thick- 
 
 Fig. 14. — Sectional View of Tampons in situ when the 
 Patient is in the Erect Posture. 
 
 ened tissues, but the comparatively painless applica- 
 tion of a continuous current of galvanism is employed 
 to accomplish the same purpose. Galvanism has been 
 employed with great success to cause the absorption 
 of old exudations in other parts of the body, but it 
 
- 8 9 — 
 
 " has been only indifferently appreciated by gyne- 
 cologists," as stated by Rockwell* 
 
 This writer also alludes to the fact that while this 
 agent has been long known to be efficacious in pro- 
 moting the absorption of the products of inflamma- 
 tion it is only within a comparatively recent period 
 that it has been " tested in the thickening and infiltra- 
 tion resulting from inflammation of the pelvic cellular 
 tissue." The author has used it in a limited number 
 of cases with the best of results, but in order to speak 
 authoratively he prefers to quote from the distinguish- 
 ed writer just referred to, who states that he " has 
 seen this treatment, persistently and judiciously car- 
 ried out, melt away large pelvic deposits." The 
 "negative pole of the galvanic battery, which may con- 
 sist of a metal ball, is the one that should be applied 
 internally. Apostoli in this class of cases, used nega- 
 tive electro-puncture, having the currents very strong, 
 from which he claims excellent results. 
 
 In cases of dysmenorrhea apparently dependent 
 upon previous pelvic inflammation, where the ovaries 
 are imprisoned by strong, dense adhesions, and it is 
 believed that the structural changes are not sufficient 
 to demand the removal of the ovaries, a few operators, 
 the first of whom was probably Prof. Polk, of New 
 York, feel justified by the good results they have ob- 
 
 *Electricityin Gynecology." American System of Gyne- 
 cology, Vol. i. 
 
— 9© — 
 
 tained, in making abdominal incision, breaking up the 
 adhesions and thereby restoring the ovary to its 
 normal position. 
 
 This new and novel operation requires time and 
 experience to determine its field of usefulness. 
 
 Occasionally the sufferings from the form of dys- 
 menorrhoea designated as ovarian, is so great and its 
 debilitating effect upon the nervous system so pro- 
 found, that life is rendered unendurable. Under these 
 circumstances oophorectomy has shown both brilliant 
 results and signal failures, the larger proportion of 
 cases has been benefitted, a less number has been un- 
 changed as far as pain is concerned. This operation 
 finds a wider field of usefulness in those cases where^ 
 suppuration has taken place, either in the ovaries or 
 tubes and the frequently recurring local peritonitis or 
 cellulitus which results therefrom, is continually en- 
 dangering the patient's life. But these cases, although 
 attended by much pain, are not always subject to a 
 severe form of painful menstruation, consequently are 
 without the boundaries of the present subject. The 
 removal of the ovaries and tubes is always a dernier 
 ressort and belongs more especially within the domain 
 of abdominal surgery, but as the author has endeavored 
 to treat the subject of disorders of menstruation rather 
 more from the physician's than the surgeon's stand- 
 point, he merely alludes to it with the conditions 
 where it is indicated and justifiable. 
 
— 9 i — 
 
 DERANGEMENTS OF THE CLIMACTERIC. 
 
 That period in a woman's life which extends 
 from the beginning of the irregularities which precede 
 the cessation of the menstrual flow to the subsequent 
 re-establishment of her health is designated as the 
 climacteria (Latin), menolipsis (Greek), the climac- 
 teric, change of life, turn of life, critical time (Eng- 
 lish), menopause, temps critque, age de retour 
 (French), aufhoren der monatlichen reinigung (Ger- 
 man). There are two rather indefinite divisions of 
 this period for which there are no technical terms. 
 The first is ushered in with the signs of the com- 
 mencement of failure in ovarian and uterine functional 
 activity, and ends with menstrual cessation. It is 
 commonly known as the ' dodging time.' The second 
 lasts from the final disappearance of the menstrual 
 flow till the re-establishment of health. 
 
 There is no doubt but that in the great majority 
 of women this apparent boundary line between the 
 two divisions of the climacteric period, viz. : cessation 
 of menstruation, coincides in point of time with the 
 true one which is, failure of ovarian function or cessa- 
 tion of ovulation. But there are instances in which 
 ovulation does not cease with the disappearance of 
 the monthly flow. That this is a fact, is proven by 
 the recorded cases of pregnancy occurring after this 
 cessation. 
 
 Date of the Climacteric. — The large majority • 
 
— 9 2 — 
 
 women, cease to menstruate between the ages of forty 
 and fifty. Tilt has averaged the time in 1,082 cases, 
 of whih 501 were his own, 400 Guy's, and 181 those 
 of Brierre de Boismont, and found it to be at forty- 
 five years and nine months. Although this is the 
 general average for temperate climates, there are 
 deviations from it in different localities of the same 
 latitude. The average length of menstrual life is 
 thirty-two years. There exists a great difference of 
 opinion among medical writers as to the effect of 
 early or late menstruation on the length of this period. 
 Observers have also disagreed as to the influence 
 which premature or delayed menstruation has upon 
 the period of cessation. In thirty-three cases of early 
 menstruation occurring between the ages of eight and 
 eleven, observed by Tilt, the average date of the ces- 
 sation was two years earlier than in thirty-seven other 
 cases where menstruation had begun late, between 
 the ages of eighteen and twenty-two. This shows 
 that delayed puberty can sometimes retard the ap- 
 pearance of the menopause. It has, however, been 
 the experience of most observers, such as Brierre de 
 Boismont, Dusourd, Guy, Frank, Hanover, Cazeau, 
 Krieger and Kisch, that the duration of menstrual 
 life is longer in those who menstruated early and vice 
 versa, except where menstruation has appeared very 
 early or very late; under both of these circumstances, 
 cessation comes on early as a rule; though some out 
 of the thirty-seven cases previously mentioned as cited 
 
— 93 — 
 
 by Tilt, were those in whom it first appeared as late 
 as twenty or twenty-two and was greatly prolonged. 
 And on the other hand, Descuret cites an instance of 
 a woman who menstruated at two years of age, mar- 
 ried at twenty-nine, had a large family and did not 
 cease to menstruate till the age of fifty-three. Queirel 
 and Rouvier are of the opinion that the date of the 
 menopause is not particularly influenced by the early 
 or tardy appearance of menstruation. 
 
 The duration of menstrual life seems to corre- 
 spond to the amount of ovarian energy possessed. If 
 the latter is considerable it shows itself in the early 
 development of the ovarian and uterine functions and 
 their late disappearance. 
 
 Other circumstances which have an influence in 
 determining the natural coming of the menopause are, 
 climate, elevation of locality, soil, race, mode of life, 
 social condition. 
 
 The most striking example of the influence of 
 race is that of the Jews; they inhabit all parts of the 
 earth, both hot and cold climates; but wherever their 
 habitation, they show a marked tendency toward an 
 early climacteric although the age of puberty with 
 them is also early. 
 
 Numerous and frequent pregnancies sometimes 
 hasten the arrival of the climacteric on account of the 
 strain they produce on the whole system. The forces 
 which are connected, either nearly or remotely, with 
 procreation and which are designed to extend over a 
 
— 94 — 
 
 certain period, may, possibly, by rapid expenditure be 
 exhausted in a much shorter space of time. Kisch is 
 of the opinion that the change of life takes place 
 earlier in the laboring than the wealthy class. 
 
 On the other hand, the date of the menopause is 
 sometimes normally delayed much beyond the average 
 time. A healthy, protracted ovarian activitv goes 
 hand in hand with exceptional constitutional vigor. 
 It is a function of vegetative life and when its power 
 does not begin to decline until after the usual time, it 
 denotes an extraordinary vitality which results in 
 longevity. 
 
 Instances of menstruation continuing up to the 
 sixtieth, seventieth, or eightieth year are interesting 
 because of their infrequency, but they cannot claim 
 the importance that is due to those in which there is 
 not only late menstruation but also late conception. 
 These latter are of two kinds: first, those in whom 
 menstruation has continued up to the time of concep- 
 tion; and, second, those in whom conception has taken 
 place after cessation and it was supposed that the turn 
 of life had passed. Those who conceive late — after 
 the age of fifty — have usually borne several children 
 earlier in life, although late marriage has been thought 
 to have an influence; but cases have been reported 
 where conception was not only comparatively late, but 
 fecundity was extremely late. Tilt mentions an ex- 
 ample of a woman who married at eighteen and was 
 never pregnant till she was forty-eight, when she had 
 
— 95 — 
 
 a child. Schmidt has reported a similar instance of a 
 healthy woman who married at nineteen and did not 
 become a mother until the age of fifty. 
 
 The second class of late conceptions have more 
 interest for us than the first, since there is a diversity 
 of opinion concerning them. Some hold that there is 
 a return of ovarian activity as a result of some unusual 
 influence; and it has even been likened to the occa- 
 sional renewing of the sight or hearing in the old. 
 Others think that there is a persistence of the ovarian 
 function, although menstruation has ceased some time, 
 never to return, or possibly to return after a long 
 period. When there is a reappearance of menstrua- 
 tion, it is ordinarily a few months before conception 
 takes place. This latter explanation is probably the 
 true one. One case came under the author's observa- 
 tion of a woman fifty-five years of age, who, a year 
 after menstruation had ceased, became pregnant and 
 gave birth to a living child, but the child died from 
 inanition the third day after its birth. 
 
 Duration of the Climacteric in the Normal Condi- 
 tion. — The time of the change is about equally di- 
 vided into the pre-cessation and post-cessation periods, 
 and its entire duration is normally from two to three 
 years. Tilt, in his five hundred tabulated cases, re- 
 corded one hundred and thirty-seven in whom cessa- 
 tion was sudden and without prodromata; in two 
 hundred and sixty-five, the " dodging time " lasted 
 from one month to eighteen years, making an average 
 of two years and three months. 
 
- 9 6- 
 
 The duration of the post-cessation period is as 
 difficult to define as that of the pre-cessation, as very 
 frequently the changes which take place are so grad- 
 ual as to be imperceptible. From the observation of 
 three hundred and eighty-three cases, Tilt concludes 
 that the nervous symptoms and other phenomena of 
 the menopause will have disappeared within three or 
 four years. This would make the whole duration of 
 the change from five to seven years in length, which 
 seems considerably longer than others, including the 
 author, have observed. Two to four years is the 
 average length of time. The long period observed by 
 Tilt and a few others might cause one to believe that 
 some form of disease, either local or general, may 
 have influenced its prolongation. 
 
 Normal Appearances and Conditions at the Climac- 
 teric. — Tilt* says: " Puberty and the change of life 
 are caused by anatomical changes, the one by ovarian 
 evolution, the other by ovarian involution" 
 
 At puberty the ovaries increase in size, whereas 
 at the climacteric period they decrease. After cessa- 
 tion instead of being smooth and turgid they shrivel, 
 and it is extremely difficult to trace the cavities of the 
 Graafian vesicles. Later in life they are still more 
 atrophied and their existence merely indicated by a 
 small fibro-cellular substance. With this change in 
 the ovaries are corresponding changes in the Fallopian 
 
 * The Change of Life, by Edward John Tilt, Philadelphia > 
 1871. 
 
— 97 — 
 
 tubes and the uterus, the vagina becomes narrower 
 and shorter, while the vascular supply is diminished 
 by the gradual shriveling up of the pampiniform 
 plexus. In the beginning of the change the vagina is 
 almost always uniformly hyperaemic, but as the vessels 
 atrophy the hyperaemic condition disappears in locali- 
 ties so that there will frequently be observed dark red 
 spots on a pale ground. The rugae of the vagina 
 gradually disappear and after a time the mucous 
 membrane presents a uniformly pale or grayish color. 
 The introitus vaginae becomes narrowed and its 
 mucous membrane changes and presents a similar ap- 
 pearance to the one already described. The adipose 
 tissue about the mons veneris and labia gradually dis- 
 appear. The mammary glands which are frequently 
 congested and painful at the beginning of the climac- 
 teric, after its occurrence become atrophied — the 
 glandular structure disappearing, although frequently/ 
 in its place are fatty deposits. 
 
 Pathological Conditions Occurring at the Climac- 
 teric. — The variations in the date of the menopause 
 heretofore mentioned were of purely a physiological 
 origin and were frequently due to individual organic 
 peculiarities. Deflections from the normal line, how- 
 ever, whether resulting in premature cessation or ab- 
 normal prolongation of menstruation, are more com- 
 monly in consequence of some pathological change, 
 primarily in the nervous and circulatory systems with 
 
 8 u 
 
- 9 8- 
 
 secondary effects upon the ovaries and uterus; or 
 primarily in the ovaries or uterus. 
 
 Premature menopause is more frequently brought 
 about by changes in the ovaries than other pelvic 
 organs. 
 
 The three forms of inflammation of the ovary, 
 viz., peri-oophoritis, interstitial and parenchymatous 
 oophoritis may all, if severe, produce the same final 
 result, viz., destruction of the Graafian vesicles. 
 Primary peri-oophoritis is caused by gonorrhceal in- 
 fection, extension of inflammation from the tubes 
 either acute or chronic, and suppression of the 
 menses. Secondary peri-oophoritis results from gen- 
 eral or local peritonitis and may also accompany in- 
 terstitial puerperal oophoritis. In both the primary 
 and secondary varieties, when severe exudations are 
 from time to time poured out around the ovary, or 
 dense pseudo-membranes form, which by subsequent 
 contraction, compress and destroy the follicles 
 (Olshausen). 
 
 Interstitial oophoritis is caused principally by dis- 
 eases of the puerperal state. There is first an increase 
 of the cellular tissue surrounding the Graafian vesicles, 
 which, by its density, prevents them from rupturing; 
 afterwards it contracts and destroys them by cutting 
 off their blood supply. 
 
 Parenchymatous oophoritis may be caused by 
 local peritonitis. The functional activity of the ovaries 
 may also be destroyed by benign or malignant disease. 
 
— 99 — 
 
 Atrophy of the uterus may cause early appear- 
 ance of the menopause. This abnormally premature 
 senile condition of the uterus may follow difficult 
 labors, puerperal metritis, puerperal peri-metritis and 
 para-metritis, puerperal super-involution, and abortion 
 with profuse hemorrhage. 
 
 Those general diseases or conditions which may 
 have a secondary effect upon the uterus and ovaries 
 with destruction of their functions, are those which 
 produce mental or physical shock or greatly exhaust 
 the vital forces. Of the former there are, sudden 
 fright or grief, and great anxiety, a severe cold or wet- 
 ting at the menstrual period; of the latter there are, 
 typhus, cholera, septicaemia, recurrent fever, the exan- 
 themata, poisoning, as by arsenic and phosphorus 
 (Myschkin), mercury (Hinsberg), alcohol and opium 
 (Puech), continued diarrhoea, venesection or drastic 
 purgatives at the menstrual period. 
 
 A sudden amenorrhcea which may follow any of 
 the acute infectious diseases (cholera, yellow fever) or 
 the exanthemata, may prove to be a premature meno- 
 pause. The investigations of Slavjansky in cases of 
 cholera, typhus and similar infectious diseases and the 
 studies of Lebedinsky in scarlet fever, show that in 
 both, when the genital organs are affected, there has 
 been an occurrence of the third form of ovarian in- 
 flammation previously mentioned, viz: parenchymat- 
 ous oophoritis. In this form the inflammation begins 
 in the Graafian vesicles and frequently does not extend 
 
IOO 
 
 much beyond them; consequently the ovary may not 
 have increased in size nor changed in macroscopic ap- 
 pearance. 
 
 Paralysis of the lower half of the body has also 
 been mentioned as causing complete cessation in young 
 women. 
 
 One of the most frequent conditions a physician 
 is called upon to treat about the time of the meno- 
 pause is uterine hemorrhage. Allusion has already 
 been made to this in connection with fungosities and 
 malignant disease. As heretofore stated, uterine 
 fungosities are very common at this age and polypi 
 are especially liable to develop. While a flow of 
 blood is liable to occur in consequence of any of the 
 pathological conditions just mentioned, it is neverthe- 
 less true that not infrequently, hemorrhage occurs at 
 this time from causes not easy to explain. Scanzoni 
 is of the opinion that in many instances, the loss of 
 blood is due to the senile rigidity and friability of the 
 uterine vessels, which are not in a condition to offer 
 sufficient resistence to the blood-pressure that is 
 brought to bear on their walls. Kisch attributes men- 
 orrhagia at the climacteric to the softening and relax- 
 ation of the uterine tissues. Doubtless the cause in 
 many instances is in consequence of some circulatory 
 disturbance in the pelvic organs or obstruction, where- 
 by the outflow of blood is hindered and a chronic stasis 
 in the uterine walls is produced. Borner attributes 
 the menorrhagia in these heretofore inexplicable cases 
 
IOI 
 
 to vasomotor disturbances, such as those in other 
 regions which frequently characterize the menopause. 
 Allusion was made under the head of menorrhagia and 
 metrorrhagia to the frequncy of uterine hemorrhage 
 and the necessity, if rational treatment is instituted, 
 of ascertaining if possible the cause of the flow. 
 
 As it is at the climacterium malignant diseases of 
 the uterus are liable to develop, and the subject is of 
 such great importance, the author may be excused if 
 he again urges upon his readers the necessity of 
 thoroughly investigating the causes of hemorrhage oc- 
 curring at this epoch of a woman's life. Many times, 
 if examination had been made earlier, cancer of the 
 cervix would not have reached a hopeless stage before 
 the true nature of the disease was discovered. Clini- 
 cal observation leads to the belief that cancer of the 
 cervix uteri occurs more frequently just preceding or 
 at the time of the menopause, while cancer of the 
 body of the uterus is most common after the climac- 
 teric is established. 
 
 While the climacteric period exerts such an influ- 
 ence as has been alluded to in developing malignant 
 diseases, almost an opposite influence is exerted upon 
 fibrous tumors of the uterus. While it is true that 
 during the menopause these tumors seem to increase 
 in size, doubtless on account of increased vascularity, 
 it is no less true that after the change is established, 
 they undergo marked diminution. The climacteric 
 seems to exert another peculiar influence in the trans- 
 
102 
 
 formation of fibromata into sarcomata. Sussdorff* 
 refers to it as follows: 
 
 "Although most of the functional and organic 
 affections of the female genital organs decrease in 
 severity after the menopause, in a considerable num- 
 ber of cases exactly the opposite occurs, so that 
 benignant degeneration may even become malignant." 
 
 Hemorrhages of a vicarious character sometimes 
 occur in other parts of the body at the time of the 
 climacteric. The most common are from the stomach, 
 nose, lungs, or from hemorrhoids. Every case of this 
 kind demands careful and thorough investigation. 
 The nervous mechanism of these hemorrhages has 
 been explained as follows:f 
 
 " The cessation of menstruation causes an in- 
 crease in vascular tension, and consequent irritation of 
 the vaso-motor centres. Various local haemostases 
 result, which cause the symptoms of suffusion of the 
 face, tinnitus, headache, giddiness, etc. In a limited 
 number of cases these local congestions are relieved 
 by the escape of blood." 
 
 Leucorrhcea is of common oocurrence in connec- 
 tion with the change of life, and while sometimes due 
 to some local disorder, it is more commonly in the 
 
 *N. Y. Med. Record, Dec. 2r, 1878. 
 f Pepper's System of Medicine, Vol. IV. 
 Functional Disorders of the Menopause, by W. W 
 Jaggard. 
 
— 103 — 
 
 absence of local or general disease, simply an effort of 
 nature to relieve congestion of the pelvic organs. 
 
 Displacements of the uterus are to be treated 
 when occurring at the change of life on the same 
 general principles as at other periods. As regards 
 the use of pessaries the senile changes in the geni- 
 talia super-added to changes incident to the climac- 
 teric often entirely preclude the use of the so-called 
 lever pessaries or any modifications of the Hodge, 
 such as Albert Smith's, Emmet's and others. The 
 reason one is not able to use lever or exclusively 
 vaginal pessaries, in such instances as last referred to, 
 is that they cannot be retained, owing to the changes 
 mentioned; and as it is often important that a pessary 
 should be employed to hold up the uterus, on account 
 of the displacement of the bladder and other pelvic 
 organs, pessaries which are rarely admissible with 
 menstruating women, particularly such as have a 
 uterine cup or ring with a stem fixed in an abdominal 
 belt, are often the most serviceable support that can be 
 used. Occasionally a surgical operation to restore the 
 perineum and posterior vaginal wall is advisable. 
 
 Vaginitis is a disorder of not infrequent occur- 
 rence at the menopause. This affection is often ac- 
 companied by a sense of internal heat, bearing down 
 pain, with considerable disturbance of the bladder, 
 while the passage of the urine may be attended by a 
 scalding sensation. The discharge from the vagina is 
 often purulent, possessing an offensive odor and* fre- 
 
— 104 — 
 
 quently chafes the external parts by reason of its 
 acridity. Tilt is of the opinion that women who have 
 suffered much from uterine disease prior to the change 
 of life, are peculiarly liable to attacks of vaginitis after 
 it has occurred. 
 
 Disorders of the digestive organs are among the 
 frequent accompaniaments of the menopause. Sir J. 
 Y. Simpson, Tilt, Robert Barnes, and many others 
 have expressed the opinion that functional derange- 
 ments of the liver are peculiarly liable to occur with 
 the change of life. Women at this time sometimes 
 complain of nausea and vomiting, a disagreeable taste 
 in the mouth, frontal headache, high colored urine 
 and other symptoms which are common in connection 
 with functional disorders of the liver. Dyspepsia, diar- 
 rhoea, and flatulence are of common occurrence. 
 Constipation is a frequent accompaniament of the 
 climacteric period, although not necessarily in conse- 
 quence of it. If already existing, it is liable to be 
 aggravated by the cfiange of life. The obstinate con- 
 stipation of this period is doubtless due to an atonic 
 condition of the intestinal canal. The same may also 
 be said of diarrhoea which is an occasional disorder of 
 this period. Doubtless many of these functional 
 disturbances of the intestinal canal are purely 
 neurotic. 
 
 The urinary organs are often disordered in con- 
 sequence of the cessation of menstruation. The 
 emunctory office of the menstrual flow, without ques- 
 
— io5 — 
 
 tion imposes extra labor upon the kidneys after the 
 establishment of the climacteric. The urine at this 
 time is frequently thick and contains much sediment, 
 more commonly urates. 
 
 The most numerous and prominent disorders oc- 
 curring at the change of life are of the nervous system 
 and are apparent in the neuroses occurring in the 
 various parts of the body. Tilt attributes these 
 numerous functional disorders to disturbances of the 
 sympathetic system alone, but when the physician is 
 called to treat them it is found impracticable to sepa- 
 rate disorders t>f the ganglionic system from those of 
 the general nervous system. Hysteria with its multi- 
 form disturbances is one of the common disorders in- 
 cident to the menopause. There is no form peculiar 
 to this period, as its symptoms are the same at what- 
 ever age it occurs. At the change of life, the same as 
 at other times, any one of the nervous affections may 
 be quite perfectly counterfeited. Tilt expresses the 
 opinion that hysterical symptoms at the menopause are 
 much less common among the poor than among 
 women whose nervous systems are wrought up to an 
 artificial state by luxurious living, by overworking the 
 mental faculties, and still more by the over-develop- 
 ment of the emotions. Convulsions followed by coma 
 or delirium are occasionally met with. Tilt refers to 
 a light variety of coma which he designates as pseudo- 
 narcotism. Occasionally functional paralysis takes 
 place at this time. 
 
— 106 — 
 
 Spurious pregnancy is one of the hysterical mani- 
 festations occasionally met with at the climacterium. 
 The abdomen enlarges, the breasts may be swollen and 
 tender, while nausea and many of the sympathetic de- 
 rangements of pregnancy are closely imitated. But 
 the careful diagnostician will rarely be deceived re- 
 garding the existence of pregnancy as an examina- 
 tion will reveal the absence of the characteristic signs. 
 Occasionally an anaesthetic will be required to per- 
 fect the diagnosis. Of the same character are the 
 phantom tumors which occur among hysterical women, 
 sometimes observed at the close of menstruation. 
 
 Melancholia and hypochondriasis are not uncom- 
 mon and it has been believed by many that this time 
 is peculiarly liable to develop insanity. The climac- 
 terium has been for a long time supposed to be one 
 of the most prolific of any other period of a woman's 
 life of uncontrollable impulses. It is true that the 
 mind may be perverted at this time, but it is not 
 proven that moral perversion or uncontrollable im- 
 pulses occur more often with the change of life than 
 in the puerperal state, but possibly oftener than at 
 other times. As a rule the various mental derange-^ 
 ments here alluded to wholly disappear with the re- 
 establishment of health. 
 
 There is one condition met with in connection 
 with the cessation of menstruation, regarding the 
 pathology of which there is a marked difference of 
 opinion, viz., cerebral hyperemia. The frequent head- 
 
— 107 — 
 
 aches, dizziness, ringing in the ears, drowsiness, suffu- 
 sion of the face, and full pulse, are the symptoms at- 
 tributed by some authors to cerebral hyperemia in 
 consequence of plethora. Cohnheim states that, " ex- 
 cept as a transitory state, plethora does not occur 
 under any circumstances." The pathologists of whom 
 he is an exponent, attribute the appearance which has 
 been called plethora to vaso-motor disturbances; the 
 amount of peripheral blood may thus be increased 
 without any increase of the total mass. The increased 
 nervous disturbances of this period often manifest 
 themselves in sudden profuse sweating. This symp- 
 tom may be alternated with sudden flushes or " flashes 
 of heat." Among the so-called neuralgias of most 
 frequent occurrence are mastodynia, inter-costal neu- 
 ralgia, lumbago, and myalgia in various parts of the 
 body; also neuralgic pains along the course of the 
 spinal column and in the sacrum. 
 
 Women undergoing the change of life frequently 
 complain of heart troubles, often there will be a sud- 
 den increase in the frequency of the pulse, while pal- 
 pitation is even more common. 
 
 Clement* calls attention to an affection of the 
 heart occurring at the climacterium, which he desig- 
 nates cardiopathie de la menopause. This affection is 
 characterized by palpitations, which are progressive in 
 severity, sometimes coming on with vertigo, precordial 
 
 Lyon Medicale, August, 18S4. 
 
— 108 — 
 
 pain, and dyspnoea. Later there is a tendency to at- 
 tacks of fainting, while the pulse is small and irregular. 
 This author directs especial attention to the condition 
 of anaemia which accompanies this disorder of the 
 heart. 
 
 A disorder of frequent occurrence with the change 
 of life is obstinate pruritis of the genital organs. The 
 sufferings attendant upon this affection are often ex- 
 treme, more especially as the ordinary local treatment 
 of pruritis occurring at other times often utterly fails 
 to have a beneficial effects upon pruritis of the meno- 
 pause. 
 
 There are some affections of the skin which seem 
 to occur oftener at the beginning of menstruation, 
 and also at the close, such as acne rosacea, erythema, 
 prurigo, eczema ana urticaria. 
 
 Treatment. — If one has occasion to consult 
 authorities to aid in the treatment of any of the 
 disorders of the menopause, he cannot but observe 
 the paucity of literature on the subject. Consequently 
 the author cannot present such a variety of opinions, 
 based upon the observations of others as otherwise 
 could be done. 
 
 There are, in general, two conditions which are 
 nearly always present in marked disorders of the 
 climacteric period, viz., anaemia and lowered nerve 
 tone; therefore, in the treatment of these affections, 
 this fact should be borne in mind. Such systemic 
 remedies as iron, the bitter tonics, and mineral acids, 
 
— 109 — 
 
 and preparations of strychnia and nux vomica and 
 phosphorous are usually indicated, while . remedies 
 having a depressing effect, upon the nervous system 
 and spanaemics are as a rule to be avoided. It is only 
 rarely that we meet with cases in which there is so 
 much plethora as to demand depletory measures like 
 wet' cups, leeching, cathartics, or in which there is 
 sufficient nerve vigor to be benefitted by or even to 
 endure a long continued use of bromides of the alka- 
 line bases for the alleviation of nervous irritability. 
 
 The inclination to sluggishness of the liver, skin 
 and kidneys should be overcome by remedies which 
 will stimulate them to a normal activity. 
 
 The circulation should be increased, not only by 
 increasing the amount and improving the quality of 
 the blood with tonics, but also by stimulating the cir- 
 culatory powers by the administration of digitalis or 
 convallaria, and by such mechanical means as massage 
 and abundant, gentle out-door exercise. 
 
 Now as regards the local treatment of affections 
 of the genital organs, it is well to bear in mind that 
 not infrequently, the change occurs while the uterine 
 tissues — particularly the endometrium- — is in an un- 
 healthy condition, so that it is not rare to find chronic 
 congestion characterized by marked hyperesthesia of 
 some portion of the living mucous membrane. 
 Topical remedies, such as iodized phenol or pure car- 
 bolic acid are applicable the same as in a like condi- 
 tion at other times of life. Depletory treatment, ex- 
 
no 
 
 cept in active congestion, should usually be avoided, 
 more commonly stimulating measures are indicated. 
 The " dry treatment " which is not followed by the 
 characteristic watery discharge attended upon the use 
 of tampons saturated with glycerin, is particularly ap- 
 plicable for this class. Dr. Wylie calls attention to 
 the fact:* that women who have suffered from dys- 
 menorrhcea during menstrual life, may have very dis- 
 tressing symptoms at or after the climacteric from the 
 same cause, viz., hyperesthesia about the internal os. 
 Forcible dilatation and the application of pure car- 
 bolic acid to the endometrium produces marked 
 diminution or even entire subsidence of the many dis- 
 tressing phenomena. 
 
 Vaginitis occurring at or after the menopause is 
 seldom acute, not rapid in its inception and exceed- 
 ingly persistent. The systematic remedies previously 
 mentioned, which have an influence on the nervous 
 system, are, perhaps, more important than local ap- 
 plications, although the latter are also demanded. In 
 spite of the great hyperesthesia in these cases, a small 
 Sims' speculum (for rectal examination) can be used 
 to expose the vaginal wall. A small quantity of oxide 
 of zinc or sub-nitrate of bismuth may be dusted on 
 the surface or placed upon one or more long, small, 
 flat pieces of cotton or wool which have been lubri- 
 cated with vaseline; these serve not only as a means 
 
 *Loc. Cit. 
 
— Ill — 
 
 of medication but also to separate the irritated vaginal 
 walls. Iodoform applied in the same way often gives 
 great relief. The greatest objection to the use of 
 iodoform is its offensive odor, but this may be largely 
 overcome by mixing it with balsam of Peru which also 
 has a beneficial influence upon the diseased mucous 
 membrane when it is not in a state of active conges- 
 tion. 
 
 Of the vaginal injections, the ones which are the 
 most serviceable, are: fluid extract of hammamelis, 
 one part to six or more parts of water— it should be 
 sufficiently diluted to prevent smarting — or, a tea- 
 spoonful of powder of equal parts of borax and hypo- 
 sulphite of soda, to a pint or more of water. 
 
 If the vaginitis seems to be continued, which it 
 frequently is, by an irritating discharge from the uter- 
 ine cavity, special attention must be devoted to chang- 
 ing its abnormal character by applications made di- 
 rectly to the endometrium. 
 
 Since disorders of the intestinal tract are more 
 frequently due to defective innervation than to any 
 diseased state, remedies especially adapted to this con- 
 dition are indicated. Flatulence is caused by intesti- 
 nal atony or lack of bile. Ox-gall combined with nux 
 vomica or sometimes with ginger will therefore be 
 found useful. 
 
 5 Fellis bovini, gr. xxiv. 
 Ext. nucis vom., gr. vi. 
 M. Et. Divide in capsules No. xii. 
 Sig. — One three times a day. 
 
112 
 
 Bilious attacks during the post cessation period 
 occur with some. After one or two the patient usually 
 knows when one is coming on and can prevent or 
 lessen it by some preparation like the following: 
 
 I£ Mas. hydrarg., gr. iv. 
 
 Pulv. rhei 
 
 Ext. gentian, aa gr. xxiv. 
 M. Et. Divide in pilulas No. xvi. 
 Sig. — Take one three or four times a day for several days. 
 
 In place of the above four or five grains of muri- 
 ate of ammonium in a wineglass of cold water three 
 times a day between meals will be found serviceable 
 for the same disorders. 
 
 The hygienic treatment of cases, in which there 
 are aggravated nervous symptoms, is of paramount 
 importance. 
 
 When there is cerebral hyperemia the diet should 
 not be stimulating nor difficult of digestion. 
 
 The circulation should not be interfered with by 
 tight clothing. 
 
 In cerebral hyperemia general plethora is by no 
 means an ever potent factor, and unless the former is 
 so intense as to demand active interference the more 
 powerful depletory measures, like wet cups, venesec- 
 tion or drastic cathartics, are not called for. 
 
 In marked cerebral hyperemia the drug which 
 neurologists seem to depend upon as a sheet anchor, is 
 ergot, administered usually in the form of ergotine. 
 In a like condition occurring at the menopause the 
 
— H3 — 
 
 same drug is applicable. The occasional use of the 
 bromides or chloral may be required; but the tinnitus 
 and cerebral pressure will often disappear from the 
 action of the ergot alone, and quiet sleep at night will 
 frequently ensue. Against sleeplessness, foot or sitz 
 baths will sometimes prove more efficient than the 
 ordinary hypnotics. The bath should be at a tem- 
 perature of 104 to 108 F., and should last twenty to 
 thirty minutes. 
 
 Symptoms due to disturbed innervation, the re- 
 sult of anaemia, may closely simulate those of true 
 cerebral hyperaemia and, at this time of life, probably 
 occur oftener. 
 
 In cases of cerebral anaemia the bromides and 
 chloral are contra-indicated, and such remedies as 
 caffeine and nitrite of amyl or alcohol in small quanti- 
 ties can be employed with advantage. 
 
 As a rule the general nervous symptoms of this 
 period are better combated by remedies which stimu- 
 late rather than by those which depress; of such are 
 camphor, caffeine, hyoscyamus, etc. 
 
 The patient suffering from palpitations and other 
 heart symptoms of purely nervous origin may obtain 
 transitory relief from valerianate of ammonia. When 
 they are neither very frequent nor severe a temporary 
 effect is all that is required; but if something more 
 lasting and efficient is demanded the following will be 
 found useful: 
 9 » 
 
— 114 — 
 
 I£ Caffein. citrat., gr. xxiv. 
 
 Acidi hydrobrom. dil., 
 
 Syr. Limonis, 
 
 Aquae, aa § j« 
 M. Sig. — One teaspoonful. To be repeated in three to 
 six hours if required. 
 
 The different forms of neuralgia are common 
 with neurasthenic patients and many women during 
 the climacteric period are of this class. Those who 
 have suffered from dysmenorrhcea, particularly the 
 neuralgic form earlier in life, are liable to have neu- 
 ralgia in various parts of the body; and the general 
 systemic and hygienic treatment given in connection 
 with the subject of dysmenorrhcea with a neuralgic 
 element is also applicable here. In the ill-nourished 
 — -and maay neuralgic sufferers at the menopause 
 come under this category — a systematic mode of feed- 
 ing is requisite and of more value than drugs. To 
 carry out this course, together with the hygienic treat- 
 ment, successfully, it sometimes becomes necessary to 
 remove patients from their own homes for a time to 
 some well conducted sanitarium where such a course 
 can be properly and systematically pursued. In con- 
 nection with other treatment, galvanism may render 
 great service, by causing better nutrition and improv- 
 ing the condition of the nerves and nerve-centres. 
 
 Among the many topical application for the relief 
 of neuralgic pain the author has found the following 
 as generally serviceable as any: 
 
— us — 
 
 9 Chloroformi, 
 ^Etheris sulph., 
 Spts. camphorae, aa § i j . 
 
 M et f. lin. 
 
 Sig.— For pain, use as a liniment. 
 
 In myalgia occurring in any part of the body, as 
 in neuralgia, it is often requisite in the outset to admin- 
 ister morphine hypodermically to relieve the intense 
 pain, but this is -only a temporary expedient, and is 
 objectionable for reasons heretofore stated, particularly 
 if the disease is of long continuance or the patient is 
 subject to recurrent attacks. In chronic cases mas- 
 sage together with the slow interrupted galvanic current 
 will often prove of great service in lessening pain and 
 shortening its duration. 
 
 Local applications in any stage of the disease 
 may be beneficial, particularly anodyne lotions or lini- 
 ments containing aconite, belladonna, chloroform or 
 chloral. The combination of chloroform, ether and 
 camphor mentioned above is applicable in these cases, 
 and when applied on the forehead will often relieve 
 the migraine with which the class of patients under 
 consideration are frequently afflicted. As a local ap- 
 plication in myalgia and kindred affections an anodyne 
 liniment like the following will usually relieve pain, 
 even if quite severe. 
 
 fy Chloralis hydratis, 3 ij- 3 iij, 
 Linimenti saponis, § iv. 
 
 M. Sig.— Shake and apply thoroughly. 
 
— n6 — 
 
 With patients that have the appearance of being 
 plethoric or as being well nourished, saline laxatives 
 and vapor or Turkish baths are highly extolled by 
 some authors, but as the majority are anaemic and the 
 reverse of well nourished, quinia, iron, arsenic and 
 cod liver oil are more frequently indicated. In case 
 myalgia continues, chloride of ammonium in full sized 
 doses will prove to be a remedy of great value, while 
 in like conditions some advise the administration of 
 iodide of potassium in small doses 
 
 If the general condition of patients is below 'the 
 normal standard the local pain and lameness is liable 
 to continue until there is an improvement in the gen- 
 eral health. It is therefore essential and of paramount 
 importance in such instances first to adopt and next 
 to continue modes of treatment that have in view the 
 re-establishment of health. 
 
INDEX. 
 
 Page. 
 A. 
 
 Amenorrhoea i 
 
 Anodynes 61, 62, 63 
 
 Anodyne Liniment 115 
 
 Apostoli, Negative Electro-puncture 89 
 
 B. 
 
 Barker, Fordyce 25, 26, 63 
 
 Barnes, Robert 104 
 
 Brierre de Boismont 92 
 
 Borner . 100 
 
 Boro-glyceride and Alum 10 
 
 Byford, W. H 79 
 
 C. 
 
 Clement — cardiopathie de la menopause . T07 
 
 Climacteric 91 
 
 Pathological Conditions at. .97, 104, 105, in, 112 
 
 Cohnheim 107 
 
 Constipation, a Cause of Ovarian Congestion 43 
 
 a Cause of Menorrhagia 19 
 
 Curette, Use of 22, 36, 37 
 
 D. 
 
 Darrow's Speculum 83 
 
 Descuret 93 
 
 Dilatation of the Cervix. . 69 
 
 Indication for 67, 109 
 
 Contra-indication of 73 
 
 to Arrest Uterine Hemorrhage 36 
 
— Tl8 — 
 
 Page. 
 
 Douches, Hot 9, 41 
 
 Dusourd 92 
 
 Dysmenorrhcea . 43 
 
 Treatment of 56 
 
 E. 
 
 Ellinger's Dilator 34 
 
 Emmet, T . A 34 
 
 F. 
 
 Foster, F . P 41 
 
 Frank 92 
 
 G. 
 
 Galvanism for Adhesions and Exudations 87 
 
 in Non-development 4 
 
 in Dysmenorrhcea 60 
 
 Garrigues, H . J 26 
 
 Gehrung 76 
 
 Goodell 71 
 
 Guy 92 
 
 H. 
 
 Hanover 92 
 
 Hank's Dilator 70 
 
 Hinsberg 99 
 
 Hodge 103 
 
 I. 
 
 Iodine, Churchill's Tincture of 7 
 
 Saturated tincture of. 8 
 
 Iodoform 83 
 
 Disguising Odor of 11 1 
 
 J- 
 
 Jaggard, W. W ; 102 
 
— iig — 
 
 Page. 
 
 Jenk's Uterine Probe and Sound 23 
 
 K. 
 
 Kisch 94, 100 
 
 Krieger 92 
 
 L. 
 
 Lebedinsky 99 
 
 Lyman, G. H 36 
 
 M. 
 
 Menopause, Premature 96 
 
 Menorrhagia and Metrorrhagia 18 
 
 Treatment of 23 
 
 Molesworth's Dilator 71 
 
 Myschkin 99 
 
 N. 
 
 Neuralgia at the Menopause 114 
 
 O. 
 
 Oldham 50 
 
 Olshausen 98 
 
 P. 
 
 Palmer, C. D 25, 65 
 
 Peaslee's Dilators 69 
 
 Phenol, Iodized '. 8 
 
 Q- 
 
 Queirel 93 
 
 R. 
 
 Rockwell 89 
 
 Rouvier 93 
 
120 
 
 Page, 
 S. 
 
 Schmidt 95 
 
 Simon's Scoop 35 
 
 Sim's Styptic Cotton 31 
 
 Simpson, Sir J. Y 104 
 
 Smith, Albert 76 
 
 Sussdorf 102 
 
 T. 
 
 Tamponing for Uterine Hemorrhage 30 
 
 for Displacement 85 
 
 Thomas, T. G 22, 31 
 
 Tilt 93, 95, 96 
 
 V. 
 
 Vaginitis at the Menopause 103, 101 
 
 Virchow 51 
 
 Vicarious Menstruation 13 
 
 W. 
 
 Williams, J 51 
 
 Wylie, G 19, no 
 
 -0 19 M 
 
MB8H 
 
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