SECTION VIII.

DISTURBANCES OF THE MENSTRUAL FUNCTION.

CHAPTER XLVIII. Amenorrhoea: Menorrhagia Dysmenorrhoea.

SECTION IX.

DISTURBANCES OF THE REPRODUCTIVE

FUNCTION.

CHAPTER XLIX. Sterility: Abortion: Retroflexion of the Gravid Uterus.

Causes.

CHAPTER XLVIII.

AMENORRHOEA: MENORRHAGIA: DYSMENORRHŒA.

THE three subjects to which this section is devoted are not diseases, but are symptoms of a large number of the more or less well-ascertained pathological conditions already considered. Theoretically, therefore, they should not come up for special consideration; practically, however, it is of use to the practitioner to summarize the conditions causing these symptoms, and to give some special hints as to their treatment.

AMENORRHOEA.

This means cessation of menstruation during the period between Puberty and the Menopause. It is normal to have Amenorrhoea during pregnancy and lactation. Amenorrhoea may be caused by the following

Local conditions:

Congenital .

Acquired

Absence or incomplete development of uterus and annexa, atresia of the genital canal (with or without accumulation of the menstrual blood), state of Cretinism;

[ Superinvolution, simple atrophy of uterus, cystic ovarian disease, extensive inflammatory conditions of uterus and ovaries. Constitutional conditions-such as phthisis, chlorosis, pre-maturity of menopause also cause amenorrhoea.

The local conditions have already been fully described under the various heads; we give here only a few hints as to the investigation of the causes of this symptom. When the patient complains of never having menstruated and there is no constitutional cause for the amenorrhoea, the question of examination should always be entertained; abdominal palpation and rectal examination are employed to ascertain that there is no retention from atresia. To ascertain the condition of the uterus, a vaginal examination may be necessary. Sudden cessation of the menstruation in a girl neither phthisical nor chlorotic is usually due to

pregnancy; early sickness, mammary and other signs should be looked for. Nothing is a sure sign of pregnancy except the characteristic increase in the size of the uterus, agreeing with the number of periods passed.

In cases where amenorrhoea is due to chlorosis, Blaud's pills are Treatment. indicated. These contain sulphate of iron and carbonate of potash made

up as undernoted; as the result of the combination, the carbonate of iron is formed.

Nine pills must be taken per diem continuously for six to eight weeks, by which time a complete cure usually results.

Before the pills are given, the state of the tongue and bowels should be looked to. If the tongue is foul and the bowels constipated, we may give the following:

Aquam ad

zi.
gr. xxiv.

3iij.

3j.

3vi.

Sig. Tablespoonful twice or thrice daily.

This is taken for a week. The Carlsbad salts or Friedrichshall water may be substituted. This hint as to the preliminary purgation is a good one, and is given by Milner Fothergill; if not attended to, the result will be disappointing as the iron will not be so readily absorbed by the intestinal mucous membranes.

Note. The original composition of Blaud's pills is as follows:-Sulphate of iron, carbonate of potash, of each half-an-ounce; marshmallow root thirty grains; gum tragacanth q.s. to make 120 pills.

The following are the proportions in the pill as made by Messrs. Duncan, Flockhart and Co. of this city: Ferri sulph. siccat. 15, Potass. carb. siccat. 15, Pulv. gum. acaciæ 3, Syrup. simp. 9; Divide in 5-gr. pil.

Blaud's pill gives a ferrous carbonate and a potash salt, the decomposition taking place after the pill is swallowed.

In Vallet's pill, which is popular on the continent, the decomposition is effected first and the carbonate of iron thus freshly formed is used to make the pill. The quantities taken to make Vallet's pill are as follows:-Protosulphate of iron (in crystals) 10, Carbonate of soda (in crystals) 12, White honey 3, Sugar of milk 3; Divide in 5-gr. pil.

Ringer recommends Permanganate of potash. The following is a good formula:

Causes.

These pills should not be made with any excipient containing glycerine or with an oxidizable substance.

MENORRHAGIA.

Menorrhagia is the term applied to excessive hæmorrhage at the menstrual periods; when the hæmorrhage is intermenstrual, it is termed metrorrhagia.

The causes of menorrhagia are the following:-
Constitutional

Local.

Hæmorrhagic diathesis, scorbutic conditions; Endometritis, metritis, subinvolution, retroversion of uterus, inversion of uterus, submucous and interstitial fibroids, polypi, carcinoma uteri, sarcoma uteri, incomplete abortion.

It should not be forgotten that we may have menorrhagia in cardiac disease, and also in hepatic congestion (Matthews Duncan, Warner). Treatment. The treatment of menorrhagia is the treatment of the condition producing it. In cardiac disease we give digitalis; and in hepatic disease we may try chloride of ammonium, euonymium or iridin.

In cases where there is menorrhagia due to a simple congested condition or to a flabby state of the uterine muscle, we may give the following at the menstrual periods:

Note that it is well not to write "at the menstrual period" on the prescription, but to put

as directed." When the practitioner is con

sulted as to menorrhagia in unmarried ladies or young girls, he should first try the ergotin and oxide of silver pill. If this fail and the case

be urgent, he should request a local examination. the responsibility rests with the patient.

Ergot may be given also as follows:

B Ergotæ liquidi extracti

Sig. Thirty drops as directed.

В Ergotinæ

or

Fiat suppositorium: mitte tales xij.

Sig. As directed.

If this be declined,

zij.

gr. iv.

Inform the patient that two suppositories are to be passed into the rectum each morning after the bowels move.

In some cases the hypodermic injection is required (v. p. 399).

DYSMENORRHŒA.

LITERATURE. Duncan, Matthews-Clinical Lectures, p. 131. Goodell-Lessons in Gynecology: Philadelphia, 1879. Gusserow-Menstruation and Dysmenorrhoea: Germ. Clin. Lect., New Syd. Soc. Tr., 1877. Herman, G. E.-On the Relation between Backward Displacements of the Uterus and Painful Menstruation: Lond. Obst. Trans., 1882. Solowieff-Decidua Menstrualis: Archiv. f. Gyn., Bd. II., S. 66. Schroeder— Die Krankheiten der weiblichen Geschlechtsorgane: Leipzig, 1879. Simpson, Sir J. Y.-Diseases of Women, p. 225: Edin., 1872. Williams, John-Pathology and Treatment of Membranous Dysmenorrhoea: Lond. Obst. Tr., 1877.

Dysmenorrhoea may be defined as the occurrence of pain just before, during, or after the menstrual period.

The pain of dysmenorrhoea varies greatly in intensity. It may be so severe as to render the sufferer a miserable invalid, it may interfere with her work more or less, or it may cause only marked uneasiness. It is always advisable in cases of dysmenorrhoea to ascertain how much the pain interferes with the patient's occupation or whether it confines her to bed. Note also when the pain occurs-prior to, during, or after the blood-flow; in the purely spasmodic form, it is during the flow.

In order to treat dysmenorrhoea intelligently, we must endeavour to ascertain its cause and try to make out how this condition brings about the pain. We know nothing at all as to the real cause of dysmenorrhoea. We know that in many instances it is associated with certain pathological conditions, but how these actually cause the pain is as yet disputed. Some facts as to menstruation help us in understanding dysmenorrhoea. The uterus is an erectile organ (p. 68), and as the decidua menstrualis is five or six times thicker than the uterine mucous membrane, it is evident that metritis or pathological anteflexion when present will hinder