Chapter X: Front Matter (10)

As the tenderness disappears the cotton plugs may be increased in quantity, and thereby made to serve as temporary support for the uterus until a more permanent pessary can be substituted. The sluggish circulation in the pelvis and torpid condition of the bowels may be much relieved by the daily application of the wet pack. A small flannel sheet folded lengthwise to the width of two feet, dipped in very hot water, and dried by passing it through a wringer, is wound about the hips and covered by another dry one. At the end of a half hour, during which time the patient maintains the recumbent position, the sheets are removed. When the tenderness has been sufficiently reduced, gentle attempts at replacement may be made every day or two by conjoined manipulation. The patient's tolerance of manipulation may thus be observed and the way prepared for complete replacement and permanent retention after the subsidence of the inflammation.

In retroversion and retroflexion always replace the uterus before adjusting the pessary, otherwise the instrument will press upon the sensitive uterus, when one of three unfortunate results must occur: (1) The pessary may not be tolerated on account of pain; (2) the pessary may be forced down by pressure from above so near to the vulva that it will fail to do the least good; (3) the uterus, finding it impossible to hold its position against the pessary, instead of taking its proper position will often be bent over it in exaggerated retroflexion, with the cervix between {170} the pessary and the pubes and the body between the pessary and the sacrum, or the whole organ may slip off to one side of the instrument into a malposition more serious than the one for which relief is sought. The safest and most effective method of replacement is by conjoined manipulation, as represented in Figs. 16 and 17. The dotted lines in the former indicate the gradual elevation of the corpus out of the hollow of the sacrum to the pelvic brim, where it may be anteverted by the fingers of the right hand pressed well down behind its posterior wall. During the process of anteversion the index finger of the left hand in the anterior fornix of the vagina presses the cervix back to its place in the hollow of the sacrum, as in Fig. 17. Efficient reposition of the uterus is very often impossible without anæsthesia.

The replacement is not usually accomplished by drawing the fundus forward and pushing the cervix back directly in the median line. In most cases the fundus sweeps around the arc of a circle on the left side of the pelvis, and the cervix on the right. This is owing to the greater frequency of cellulitis on the left side, and consequent shortening of the left broad ligament. After replacement the organ is to be held in position by a suitable pessary.

Bimanual replacement has two great advantages over the more familiar methods of the sound or repositor: first, it is more effective and more {171} permanent; second, the lever action of the sound or repositor, by which the operator may unwittingly use an undue and dangerous amount of force, is avoided in the use of the hands, through which the operation is not only constantly under his control, but also within his appreciation.

Inasmuch as the pessary fulfils its indications by sustaining the pelvic floor, and thereby holding the cervix in the hollow of the sacrum, the same general principles, and in fact the same pessaries, which are applicable to prolapse apply also to retroversion and retroflexion. Indeed, the first step in the genesis of the retro-positions has been shown to be prolapse. The student is therefore referred to the general remarks on the adjustment of pessaries for prolapse.

The operations of elytrorraphy and perineorraphy, especially the latter, already described in the treatment of descent, are often of the utmost importance in the treatment of the posterior displacements, and should therefore be carefully studied in this connection.

In the adjustment of the pessary it is desirable, if possible, to avoid direct pressure upon any part of the uterus. Pessaries designed to prop up the body of the uterus by pressure upon the posterior wall to correct the posterior malpositions, and upon the anterior wall to correct the anterior malpositions, are very liable to induce metritis and perimetritis, and are therefore generally unsafe. In certain cases, however, the vaginal walls, {172} especially the posterior, may be so relaxed from subinvolution and other causes that the instrument, though very long, fails to maintain the cervix in its normal place. Under such conditions a pessary may be required to act directly upon the uterus. The Schultze's sleigh pessary represented in Fig. 19 fulfils this indication. Schultze's figure-of-eight pessary, or a long Albert Smith pessary with its uterine curve made so extreme as to bring the upper part of the instrument in front of the cervix instead of behind, answers the same purpose.

Thomas's retroflexion pessary, with its bulbous upper extremity, is a long narrow instrument of extreme uterine curve. It lifts the uterus very high, and is specially applicable in cases of great relaxation of the pelvic floor and of complicating prolapse of the ovaries (Fig. 21). The bulbous portion is sometimes made of soft rubber.

A properly-adjusted pessary gives to the patient no consciousness of its presence. If the instrument cause pain it should be removed and search made for the tender places; it should then, if possible, be remoulded into such shape that it will not exert pressure upon them. Often a slight indentation at some point will enable the patient to wear it with comfort.

Sometimes when the corpus has been firmly bound back by peritoneal adhesions they may be broken up by very forcible conjoined manipulation under ether, but the operation is dangerous, and should therefore be {173} undertaken only by an expert operator. In place of this operation Lawson Tait has proposed to open the abdomen, break the adhesions, and stitch the fundus uteri to the abdominal wound. This operation in the hands of such an operator as Tait is probably not more dangerous than breaking up firm adhesions by forcible conjoined manipulation.

In certain cases in which replacement is impracticable or impossible on account of inflammation or adhesions a soft rubber ring may be inserted, and will often give decided relief by lifting the uterus and pelvic floor nearer to the health level. In the treatment of all displacements coition should be forbidden or permitted only with great moderation, and the pessary should be kept clean by copious daily applications of the vaginal douche. Every three or four weeks the instrument should be removed and the pelvic organs carefully examined.

It should be urged that no man can safely apply the pessary until he has fully appreciated its indications and contraindications. Few practitioners possess naturally the mechanical skill necessary to its proper adjustment. Of this thousands of unfortunate women bear witness. Its dangers in inefficient hands are in striking contrast with its usefulness when judiciously employed.

Many cases of displacement, both anterior and posterior, are so complicated by prolapsed and adherent ovaries, by advanced disease of the ovaries and Fallopian tubes, and by peritoneal adhesions, that not only {174} replacement, but even palliation, is impossible; then, as a final resort, the activity of the pelvic organs, both physiologically and pathologically, may be put at rest by the removal of the ovaries and Fallopian tubes.

William Alexander of Liverpool has devised an ingenious operation of shortening the round ligaments for the radical cure of descent and of the posterior displacements. He reports twenty-two cases of the operation in his own practice and several more in the practice of other surgeons, with almost uniform success in completely curing the displacements. The operation, although new, gives promise of a brilliant and successful future.

Lateral Versions and Flexions.

The lateral malpositions which often complicate retroversion and retroflexion are usually the result of inflammation in a broad ligament or in the uterus itself, or in both. Their treatment is that of the causative inflammation, and follows the general principles which have been laid down for the treatment of other versions and flexions.

Pathological Anteversion.

Sometimes the physiological angle of flexure becomes obliterated in consequence of chronic metritis, resulting in permanent straightening of the uterus, and the cervix becomes elevated and fixed above, or the corpus depressed and fixed below, the normal level. This constitutes pathological anteversion (Fig. 22).

ETIOLOGY.--The exaggerated anteversion of early pregnancy is physiological, the exaggerated anteversion of the uterus in chronic metritis is pathological. Elevation of the cervix and depression of the corpus may be induced by peritoneal adhesions. Increased weight from a mural fibroid may also depress the corpus.

{175} The SYMPTOMS are due to the pelvic inflammations already mentioned and other complications. The increased weight of the uterus, which is usually hypertrophied from metritis, generally causes a dragging sensation, especially if the organ be also prolapsed. The enlarged corpus occupying the territory of the bladder often induces persistent vesical irritation or even cystitis. Menorrhagia, when present, is the result of the metritis or a fibroid rather than of the displacement per se.

DIAGNOSIS AND PROGNOSIS.--The displacement is recognized by digital touch, which discloses the anterior wall of the uterus parallel to the anterior wall of the vagina, with the fundus close to the symphysis and the cervix elevated. Conjoined examination will show the size, shape, hardness, and degree of fixation. Exaggerated anteversion of the healthy uterus is not necessarily pathological in its results. This is illustrated by the anteversion of early pregnancy. The prognosis is therefore good if the causes can be removed.

TREATMENT.--Inasmuch as exaggerated anteversion is the position taken by the uterus in chronic metritis, it follows that the treatment is often that of chronic metritis. For the treatment of metritis, perimetritis, fibroids, menorrhagia, etc. the reader is referred to the special literature of those subjects. Irritable bladder, which is often a mechanical result of the displacement and enlargement, may sometimes be relieved by means of an Albert Smith or Hodge pessary, which lifts the organ to a higher level away from the bladder. In thus elevating the uterus the {176} anteversion may be rather increased than diminished, which proves that the symptoms were dependent not upon the anteposition, but rather upon descent and antelocation. Should the parts be too sensitive to tolerate the hard-rubber pessary or a flexible rubber ring, the daily application of medicated pledgets of cotton will give support to the uterus and decrease the tenderness until the more permanent instrument can be worn. The numerous anteversion pessaries designed to elevate the corpus by direct pressure on the anterior wall of the uterus generally irritate the organ, and thereby aggravate the inflammatory complications. They are therefore to be used with extreme caution.

Pathological Anteflexion.

DEFINITION.--The normal forward bending of the corpus upon the cervix uteri when the bladder is empty makes an angle of which the approximate physiological limits are between 45° and 90°: the flexure would generally be pathological if less than 45° or more than 90°. Furthermore, if the flexure, whether it be normal or abnormal in extent, does not disappear upon filling the bladder, but remains constant under all conditions, the rigidity makes the flexure pathological. Anteflexion is therefore pathological if the mobility at the angle of flexure is increased or diminished or absent.

{177} ETIOLOGY AND PATHOLOGY.--Anteflexion may be congenital or acquired. By congenital is meant not defective foetal development, but failure of the immature child uterus to develop at puberty, a failure which usually pertains alike to the uterus, Fallopian tubes, ovaries, and vagina. In congenital anteflexion the uterus is bent upon itself almost double, the body and cervix both pointing in the direction of the pelvic outlet, with the cervix somewhat elongated and situated in the long axis of the vagina. (See Fig. 23.)

Acquired anteflexion may be simply an exaggeration of the normal flexure, due either to increased weight of the corpus from the presence of the uterine fibroid near the fundus or to unequal growth of the uterine walls or to unequal involution. A very frequent cause of anteflexion is thickening of the posterior wall of the uterus from the products of inflammation, and a corresponding atrophy of the anterior wall from prolonged pressure at the angle of flexure. Post-uterine cellulitis and peritonitis involving the utero-sacral ligaments is a frequent and discouraging complication. Sometimes the inflamed ligaments contract and drag the anteflexed uterus upward and backward, where it may be permanently fixed by peritoneal adhesions. (See Fig. 24.)

A constriction of the uterine canal at the point of flexure may, by confining the secretions above, produce inflammation in the body of the uterus, Fallopian tubes, and ovaries analogous to the cystitis, ureteritis, pyelitis, and nephritis which follow stricture of the male urethra. The {178} peri-uterine inflammations, having the relation either of cause or effect of the flexure, often bind the pelvic organs together in a mass of exudate, with resulting failure of nutrition, nerve-irritation, and constant pain, which sometimes render the patient's life miserable and useless.

SYMPTOMS AND COURSE.--The numerous symptoms due to the inflammatory and other complications should not be confounded with those of the displacement. The symptoms of anteflexion are polyuria and dysuria, dysmenorrhoea and sterility.

The vesical symptoms are produced either by the rigidity of the uterine tissue at the angle of flexure, which prevents the body from rising out of the way of the filling bladder, or by the inflammatory shortening of the utero-sacral ligaments, which, by drawing the uterus upward and backward, put the vesico-vaginal wall on the stretch, thereby causing traction upon the neck of the bladder.

The dysmenorrhoea may depend upon the presence of constriction of the uterine canal at the angle of flexure. This causes the blood to accumulate and to coagulate in the body of the uterus, from which it is expelled at intervals by uterine contractions simulating labor-pains. The pain when due to this cause is therefore always very severe just before the passage of a clot. Furthermore, the dysmenorrhoea may be caused by obstruction in the veins at the angle of flexure, which causes intense venous congestion of the entire body of the uterus; pain is then due to the pressure of the swollen vessels upon the nerve-filaments and to a consequent irritable condition of the muscular tissue of the uterus. Sometimes upon the establishment of the flow the uterine canal becomes temporarily straightened; this removes the cause of the vascular obstruction, and together with the flow gives relief.

Sterility is very commonly associated with anteflexion. The fact that dilatation and incision of the constricted canal have frequently been followed by conception has been accepted as proof that the sterility is due to the constrictive obstruction. This mechanical theory is questioned by many, who say that the dilatation cures sterility by straightening the uterus and thereby removing the venous obstruction and the consequent congestion.

DIAGNOSIS.--The educated touch which distinguishes the normal version, flexion, and movements of the uterus will appreciate the anatomical differences between pathological and normal anteflexion. The degree of flexure, the mobility or rigidity, and the size, shape, location, and consistency of the uterus may be ascertained by conjoined manipulation. The presence of post-uterine cellulitis is recognized by the pain caused in dragging the uterus slightly forward and by increased thickness and tenderness in the region of the utero-sacral ligaments, which may be felt by vaginal or rectal touch. Anteflexion is distinguished from a fibroid in the anterior wall of the uterus by the probe. When the diagnosis of anteflexion is obscured by the presence of cellulitis, it is usually better to wait for absorption of the exudate than to subject the patient to needless danger from the probe. Should it be necessary to pass the probe, the danger is decreased by gentle manipulation, which is facilitated by Sims's speculum and the latero-prone position. The common error of mistaking the normal version and flexion of a prolapsed uterus for pathological {179} version and flexion has been exposed in a previous paragraph. (See Etiology and Clinical History of Descent.)

TREATMENT.--If complicating cellulitis or peritonitis exist, in the relation of either cause or effect to the flexure, its removal becomes the prime indication, because unless removed it is a positive contraindication to the more direct treatment of the malposition itself. Chronic metritis, hyperplasia, hypertrophy, and irremovable tumors sometimes render cure impossible. Improvement of the general health, treatment of complications, and palliation then become the only resources.

The direct treatment of pathological anteflexion has for its object the straightening of the uterine canal, which is usually accomplished either by division of the cervix or by dilatation. But before considering the treatment more specifically, it should be remembered that surgical treatment of anteflexion in cases of dysmenorrhoea and sterility is only justifiable when the anteflexion is pathological. To say that most women who suffer from dysmenorrhoea and sterility have anteflexion is only saying that in the majority of such cases the uterus is in its normal position.

The Marion-Sims operation of dividing the cervix is open to two objections: first, its results are apt to be only temporary, in consequence of rapid contraction upon healing of the wound; second, it has frequently been followed by death. Dilatation by means of tents is also transient in its results, and dangerous to life. Both Sims's operation and dilatation by tents have given frequent and serious warnings in the shape of pelvic inflammations, which, if not destructive to life, have been almost as disastrous in their influence upon health.

The following, with some modifications, is an abstract of a valuable contribution[10] by Goodell of Philadelphia, in which he gives positive endorsement to rapid dilatation as proposed by Ellinger and others. The instruments recommended are two Ellinger dilators, which are preferred on account of the parallel action of their blades. The dilatation is commenced with the smaller instrument and completed with the larger, which has powerful blades that do not spring or feather. The light instrument needs only a ratchet in the handle, but the stronger one has a screw which forces the handles together and the blades apart. To prevent injury to the fundus when the instrument is open, the length of the blades is limited to two inches. The larger instrument has a dilating power of one and a half inches, and has a graduated arc in the handles which indicates the divergence of the blades. Goodell's modification of Ellinger's dilators is provided with serrated blades, to prevent them from slipping out of the canal during the process of dilatation.

[Footnote 10: _American Journal of Obstetrics_, 1884, p. 1179.]

For dysmenorrhoea or sterility due to flexion or stenosis the method of operation is as follows: A suppository containing a grain of the aqueous extract of opium is introduced into the rectum, the patient etherized, and the uterus exposed by Sims's speculum. The cervix is held by a tenaculum, and the smaller dilator is introduced as far as it will go. Upon gently stretching open that portion of the uterine canal which it occupies, the stricture above so yields that when the blades are closed they will pass higher. By repeating this manoeuvre a cervical canal is tunnelled out which before would not admit the finest probe. Should the os {180} externum or cervical canal be too small to admit the instrument, a pair of pointed scissors may be substituted, and by the same opening and closing motions the canal may be prepared for the introduction of the smaller dilator. As soon as the cavity of the uterus has been entered the handles are brought together. This dilator is then withdrawn, the larger one introduced, and its handles slowly screwed together. If the flexure be very marked, the larger instrument after being withdrawn should be introduced with its curve in the opposite direction to that of the flexure, and the final dilatation made with the dilator in this position. But in reversing the curve the operator should take care not to rotate the organ upon its own axis, and not to mistake a twist thus made for a reversal of the flexure; the ether is then withheld, and the instrument allowed to remain in place until the patient begins to flinch, when it is removed. The best time for the dilatation is midway between the monthly periods. In the majority of cases the dilatation should be carried to about one and a quarter inches. The infantile uterus which has failed to develop at puberty has thin, unyielding walls, and should therefore not be dilated more than three-fourths of an inch or an inch. In using the larger instrument it is usually necessary to have the assistant make decided counter-traction with the vulsella forceps to prevent the blades of the dilator from slipping out. The cervix is sometimes lacerated, but not sufficiently to produce unpleasant results.

Goodell's statistics include one hundred and fifty operations of full dilatation under ether, with no fatal result and without serious inflammatory disturbance. As precautions against cellulitis, peritonitis, and metritis the patient should be fortified for the operation with moderate doses of opium and full doses of quinine, and for two or three days after the dilatation this should be continued and supplemented by the application of an ice-bladder over the abdomen.

After forcible dilatation under ether the cervical canal rarely returns to its previously angular or contracted condition. The cervix shortens and widens, and the plasma thrown out thickens and stiffens the uterine walls. In a small minority of cases the operation must be repeated. Dysmenorrhoea or sterility, if dependent solely upon the flexure, is cured by the dilatation. The comparative safety of forcible dilatation in the hands of a skilful and experienced gynecologist may be contrasted with its great danger when undertaken by an operator unacquainted with the special requirements of uterine surgery. Peri-uterine inflammation is a positive contraindication to the operation.

Post-uterine inflammation, which has drawn the anteflexed or anteverted uterus upward and backward by the contraction of the utero-sacral ligaments, often produces traction upon the vesico-vaginal wall and neck of the bladder, with a constant desire to micturate. For the relief of this intractable symptom, which sometimes goes on to cystitis, Emmet has proposed a most satisfactory remedy known as his buttonhole operation of urethrotomy.[11] He makes a longitudinal opening about five-eighths of an inch long through the urethro-vaginal wall, between the meatus and the neck of the bladder, without cutting through either. To prevent the opening from healing together, the margins of the mucous membrane of the urethra are united with fine catgut sutures to the {181} margins of the mucous membrane of the vagina. According to Emmet, the operation relieves irritation due to traction on the neck of the bladder by freeing the pelvic fascia at the fixed point where it converges to its pubic attachment. The operation is equally applicable for the relief of this symptom when due to inflammation in any other part of the pelvis. The same result may be secured, but less satisfactorily, by forcible dilatation of the urethra.

[Footnote 11: Emmet's _Principles and Practice of Gynecology_, 3d ed., pp. 275 and 761.]

From personal experience the author can testify to the gratifying effects of this operation. Vesical irritation caused by post-uterine inflammation and consequent contraction of the utero-sacral ligaments is often wrongly attributed to the mechanical pressure of the anteflexed fundus uteri upon the bladder, which is manifestly impossible, if the contracted utero-sacral supports hold the entire uterus back away from the bladder.

The various anteflexion and anteversion pessaries which have been devised for the purpose of propping up the corpus are almost useless. Their false reputation depends upon the relief which they frequently give to complicating prolapse, the symptoms of which have been wrongly attributed to anteflexion or anteversion. The same pessaries therefore may be applied as in descent. (See Etiology and Clinical History of Descent.) Intra-uterine stem pessaries designed to straighten the flexed uterus are sometimes effective, and always dangerous.

{182}

DISORDERS OF THE UTERINE FUNCTIONS.

BY J. C. REEVE, M.D.

Menstruation with its disorders is the only subject to be considered under this head. In its monthly recurrence it is most intimately connected with, and dependent upon, ovulation, each menstrual discharge being the sign and evidence of the maturation and expulsion of one ovum or more. This proposition is denied by some, but the evidence adduced against it, while sufficient to show that the two processes may be dissociated, and may sometimes occur independently, is not strong enough to invalidate the truth of the general statement.

Menstruation may be entirely absent, the flow may be excessive, or it may be accompanied by severe pain; and these derangements have been designated from time immemorial as amenorrhoea, menorrhagia, and dysmenorrhoea. The time is long past, however, when these affections could be treated as distinct diseases. Each of them may be caused by influences so various--and, above all, may depend upon pathological conditions so different, and even dissimilar--that the name applied to each is indefinite, and, like the term dropsy, only incites inquiry as to some abnormal condition of which the deranged flow is the symptom. A due appreciation of this fact is of prime importance, because treatment cannot be instituted with expectation of success until the particular form of each derangement has been distinguished.

The great majority of cases of uterine derangement depend upon changes of structure. Those considered purely functional are largely in the minority, and would be still less in number with a more intimate knowledge of pathology or with greater skill in examination. No argument is needed, therefore, to show that a direct and thorough examination of the organs concerned is essential to rational treatment of this class of affections. There are obvious difficulties in the way of such an investigation, different from and far greater than attend the investigation of the diseases of any other organ of the body. With tact and proper demeanor, however, these difficulties can be generally overcome, but in any other than trifling cases, and especially in those continuing for any considerable time, the practitioner will do injustice to himself as well as to his patient if he do not insist upon this indispensable investigation.

A due appreciation of the influence of uterine disorders and diseases upon other and remote parts of the body is necessary to a correct estimate of their importance, and often of great practical value in treatment. Through the sympathetic nervous system pathological conditions of the uterus modify the processes of organic life, and by direct or reflex action {183} affect the cerebro-spinal system in its centre or at any point of its terminal ramifications. That the stomach responds readily to uterine excitations is shown in pregnancy, and uterine disease often causes disorders of the digestive organs the origin of which may not be suspected. Eructations, vomiting, and the various forms of indigestion are not uncommon. The bowels are irregular in action, constipation alternating with diarrhoea, and flatulent distension may occur even to a degree demanding special treatment. Failure of general nutrition and impoverished blood are the consequences of this disturbed digestion; without good blood there is no sound innervation, and the nervous system is soon in such a condition as to respond unduly to even insignificant impressions. Normal menstruation is marked by a nervous erethism which shows itself by irritability, fits of despondency, and exhibitions of temper. There are therefore abundant reasons why nervous diseases should be very frequently seen as a remote effect of uterine disorders.

A very large proportion of these reflex diseases first occur at the period of puberty, many present striking exacerbations at every menstrual period, and some are so closely associated with this function as to be cured only by remedies addressed to it. Headache, neuralgia, hysteria in its varied forms, chorea, catalepsy, epilepsy, and even mania, have been repeatedly shown to have their origin in the sexual organs. The reproach often directed at gynecologists, of a disposition to magnify their specialty, falls pointless before such important facts; and since it is not uncommon for diseases of organs in close proximity to the uterus, as those of the urethra, bladder, and rectum, to be mistaken for or confounded with diseases of the uterus itself, there is abundant warrant for urging the closest scrutiny as to a possible uterine origin of remote diseases, especially those of a nervous character.

Amenorrhoea.

The term amenorrhoea signifies the absence of menstruation. It occurs in two different forms: First, those cases in which menstruation has never occurred--emansio mensium; second, those in which it has disappeared after having been established--suppressio mensium.

The following pathological schedule may assist in the study of the subject. It need scarcely be said that it is not presented as correct in every particular, nor with the idea that the dividing-lines between physiological and pathological conditions can be always determined, but as a convenient guide to follow in the study of the subject:

A. Amenorrhoea (absent menstruation) from
_a_, anatomical conditions: want of development of organs,
atresia of passages;
_b_, physiological influences: delayed puberty, idiopathic;
_c_, pathological causes: constitutional diseases, disease of the
sexual organs, the cachexiæ.
B. Amenorrhoea (secondary or suppressed menstruation):
_a_, anatomo-pathological: atresia of passages, atrophy of
organs;
_b_, physiological: pregnancy, nursing, premature change of life;
_c_, pathological: besides those given above--A-_c_--are
psychical influences and exposure or taking cold during
menstruation.

{184} Absence or want of due development of some of the sexual organs is not of very infrequent occurrence. The ovaries are very rarely found wanting; they are more often checked in development and present the characteristics of early life. This condition may be the cause of delayed, irregular, or scanty menstruation, making a more or less near approach to amenorrhoea. Absence of the uterus is often combined with absence or with an undeveloped condition of the vagina, but this canal may be perfect and no change of the external organs be present to indicate that the uterus is wanting. It may also exist in a rudimentary form, and may be found corresponding in size and shape to the uterus of any period of early life.

Absence of the ovaries not only causes amenorrhoea, but checks the progress of the bodily development and prevents the sexual changes of puberty. When the ovaries are wanting there is almost always absence of the Fallopian tubes, uterus, and vagina. The symptomatology of absence of the uterus is not generally striking, the lack of menstruation being the principal sign; exceptionally, however, it is otherwise. In some cases where the ovaries are present and the uterus wanting, the most aggravated affections of the nervous system show themselves.

Congenital atresia of the genital canal may occur in any part of its course. Imperforate hymen is the most frequent as it is the least dangerous form, being more than twice as common as atresia of the vagina and three times as frequent as that of the cervix uteri. The vagina may be extremely small in calibre, closed in part or the whole of its course, or only a fibrous cord indicate where it should be. The uterus may be closed at the internal or external os; the latter is the more frequent. An occlusion at one point does not preclude the existence of other closures higher up. The effect of a closed canal with a recurring secretion above is evident, and gives rise to a well-marked class of cases. The organs above become distended, and the distension increases until an opening is made by art or the retained fluid bursts a passage for escape. This may occur outwardly with immediate relief and cure, or into the peritoneal cavity, causing speedy death. The time at which the uterus may be expected to give way under such distension cannot be stated, as the power of resistance of the organ differs and the amount of secretion each month may vary widely. Scanzoni in one case evacuated eight pounds of blood, the result of seven months' accumulation, and found the uterine wall as thin as paper. Bernutz states that the average time before interference is necessary is three or four years, and gives a case first operated upon in the tenth year of its course.

Menstrual retention is not at first indicated by pronounced symptoms. Suspicion of the nature of the case may be first excited by the severity of those symptoms which at every period announce the approach of menstruation and known as the menstrual molimen. As distension increases these become extreme, with rectal and vesical tenesmus and severe uterine colic. The nervous system sympathizes, as with all menstrual derangements, and there may be rigor, fainting, or even convulsions.

Whenever a patient presents such symptoms an examination should be insisted upon. It will generally reveal a smooth, soft, and fluctuating tumor, projecting externally if the case be one of imperforate hymen, or higher up if the vagina be occluded. If the uterus has become distended, {185} there will be a round, smooth, elastic tumor above the pubes. Diagnosis will be more or less difficult according to the seat of the obstruction. Cases of imperforate hymen may be readily diagnosed by sight, if touch and the history are not sufficient. When the occlusion is deeper, the patient should be placed under the influence of an anæsthetic. By one finger in the rectum and the thumb in the vagina, and a sound in the bladder, the seat and extent of the obstruction may be determined. Should it be necessary, the urethra may be dilated and a finger passed into the bladder in order to make a diagnosis. Rectal exploration is of great assistance in discovering the uterine enlargement and its character. Scanzoni calls attention to the difference in the cervix when the atresia is at the internal or external os. In the latter case the cervix will be obliterated; in the former, it will be unchanged. With a perfect vagina and a cervix of this character retention may be taken for an early pregnancy, especially as it is not uncommon for sympathetic mammary symptoms and gastric troubles to be present. Time will demonstrate the nature of the case if a diagnosis cannot be made at once.

The age at which the menstrual flow is established varies greatly. The average age of puberty in this country, as appears from Emmet's tables made up of 2330 cases, is 14.23 years, and these are believed to be the only American statistics. A close correspondence may be noted between this and the statistics of the four largest cities of France, which give 14.26 as the average. But that it is not unusual for the appearance of menstruation to be delayed is shown by the fact that of the above 2330 cases, 288 only menstruated at sixteen years and 254 more between that age and twenty-three. The circumstances which may influence, within physiological limits, the appearance of menstruation should be considered in connection with cases of this kind. Climate and social position are the principal ones. The epoch of puberty descends in the scale of age in proportion to the average height of the temperature of various countries, and vice versâ. Social position and city life show a marked effect in hastening puberty as compared with the simpler manners and plainer life of rural populations. It amounts to an average of something over a year, and is explained by the influence of enervating and luxurious habits, of light reading and the drama, the chief subject of both being the grand passion, but especially of a freer intercourse between, and the co-education of, the sexes, and the greater extent to which music is cultivated and enjoyed.

Among pathological conditions giving rise to amenorrhoea it would seem that disease of the ovaries should occupy the first rank in frequency and importance. The reverse is the truth. The ovaries are rarely inflamed, and when so amenorrhoea is not always the result. They are frequently the seat of cystic degeneration, producing tumors of large size, yet so long as but a small portion of one of the organs remains unaffected Graäfian vesicles may still be furnished and menstruation continue. It is by the influence of remote pathological conditions that the menstrual flow is most frequently restrained, and especially by those general affections known as cachexiæ, all of which exhibit marked depression and low grade of vital power and activity, if not more pronounced pathological processes. Chlorosis, the relations of which to menstruation are intimate, and which seems to be sometimes the offspring of {186} amenorrhoea, exerts a marked retarding influence, amounting to an average of one year and a half. The scrofulous cachexia is still more potent: Scanzoni states that of 31 well-marked cases, in 19 menstruation did not occur until the twenty-first year.

Amenorrhoea which is the result of pulmonary tubercular disease comes frequently under observation. It may occur at a very early period of the disease, before there is any great amount of deposit in the lungs, when it is rather the expression of want of vital force than of the exhausting effect of the disease. Under these circumstances it is only to the laity a subject of serious consideration; to the physician it is but a symptom.

The suppression as well as the absence of menstruation may be caused by atresia of the passages, this form differing from the congenital only etiologically, and in the fact that the flow has been once established. The acquired atresiæ are mostly the result of violent inflammations or traumatic influences. The vulva and vagina, or either, may be closed from sloughing after difficult labors or gangrene following the septic fevers. Occlusion of the cervix uteri may follow labor or amputation of the part, but a far more frequent cause is the application of severe caustics, happily less frequent now than formerly. Lawson Tait says he has never met with atresia of this part from any other cause.

The mode of diagnosis has already been given, and in regard to symptomatology there is only to be noted the statement of Bernutz, that there is far greater intolerance of retention from acquired than from congenital atresia.

Atrophy of the uterus is a normal process after the menopause, but it sometimes occurs much earlier in life, and then causes scanty and irregular menstruation or amenorrhoea. Attention was first called to this condition by Simpson as a process sometimes following parturition under the name of super-involution. Several labors in rapid succession have been stated to be a cause, but Simpson and Courty both give a case after a single birth. Uterine atrophy may also result from the pressure of tumors, and it has been observed in paraplegias the result of defective innervation.

The deranged menstruation is the one prominent symptom of this condition, and a diagnosis is to be made by exploration. The cervix is found small and the body light when lifted on the finger. Bimanual examination and the introduction of the sound will reveal the true condition of the organ. The latter process should be cautiously conducted on account of a frequent change of texture in the uterine walls which allows the instrument to pass through them with the use of but very little force.

Amenorrhoea is physiological during nursing and pregnancy. The former needs no attention, the latter only in regard to diagnosis. A sudden cessation of menstruation, the patient presenting all the appearances of good health, should immediately excite suspicion as to the nature of the cause. It needs but little experience to distinguish and manage these cases in the lower social ranks. The case is different, however, in a family of good position, with an anxious mother urgent for active measures, where no suspicions will be tolerated and the imputation of possible pregnancy be warmly resented. Time is here the sure ally of the physician, and an examination should be deferred until such a period {187} has been reached that pregnancy can be positively negatived or determined.

The influence of acute diseases in suppressing menstruation is not marked. During convalescence from them the flow frequently ceases from general debility. All chronic diseases depressing and exhausting in nature cause suppression, as albuminuria, cirrhosis, and cancer. Tuberculosis is as fruitful in interrupting the return as in preventing the appearance of the flow, and suppression from this cause is very frequent. Under impaired nutrition and depressed powers vital force is engaged wholly in maintaining existence; there is none for any function relating to the propagation of the species. In this class the disappearance is gradual; the flow becomes scanty and irregular in recurrence, and finally ceases. This form of amenorrhoea differs in no material point from the similar class already considered; it is but a symptom of disease of some vital organ or of some general abnormal condition.

Suppression from psychical influences is not at all uncommon. Fright, grief, bad news, sudden or prolonged anxiety, frequently cause this disturbance of function. The mental impression need not be very profound. Amenorrhoea is a common event with girls who go away from home to boarding-school. In these cases it is not probable that there is any pathological condition of the sexual organs; a change in their innervation is a phrase which will best serve to explain the origin of the derangement or to express our ignorance. The diagnosis of this form may be a matter of deep interest when it occurs directly after marriage, as it not infrequently does, and gives ground for the belief that pregnancy has occurred. Still more important is it when the suppression follows illicit intercourse, the fear of pregnancy then exerting a powerful emotional influence. Some cases are on record, and the writer has met with two: in both the function resumed its course after a time without remedies.

Exposure to storm, getting the feet wet, and the sudden application of cold to the genitals frequently cause suppression. All the conditions, however, are not well understood. The bathing- and fishing-women of Europe are said to ply their vocation without reference to menstruation, and to suffer no inconvenience. In these cases the increased flow of blood to the pelvic organs oversteps the narrow line which separates physiological from pathological congestion, and may even pass on to inflammation.

The SYMPTOMS are well marked--at first, local, as severe backache, increased heat and pressure in the pelvic region, discomfort passing on to pain, even uterine colic. If the impression be severe enough to affect the general system, there will be febrile action more or less intense, and various nervous symptoms, spasmodic or convulsive.

The therapeutics of amenorrhoea must be directed in accordance with the conditions which cause it. But the strictly scientific method cannot be followed at the outset. This method presupposes a direct examination of the organs as the first step. For obvious reasons this must be deferred until special symptoms show its necessity. For treatment the cases may be classified, in some instances according to the schedule, but more frequently according to the cause or leading features, and very generally without reference to whether there is absence merely or suppression of the function.

In amenorrhoea from atresia the measures of relief will be purely {188} surgical; the treatment, therefore, does not fall within the scope of this article.

The physician is frequently consulted in cases where menstruation has occurred once or twice, perhaps at long intervals, and not appearing regularly the fears of friends are excited. This is the normal course of establishment in a large proportion of cases. Time and assurance and regimen are alone needed, provided there is no evidence of deteriorated health. Absence of the function alone does not demand treatment--a fact which should be kept steadily in mind.

In a still larger class of cases the amenorrhoea depends upon, and is the direct result of, some pronounced cachectic condition, as chlorosis, scrofula, or a more or less active tubercular disease of the lungs. The treatment of this class resolves itself into that of the disease causing the derangement, and the reader is referred to the articles on the corresponding subjects.

The cases requiring more direct consideration therapeutically are those closely allied to the preceding, in which delay in appearance depends upon want of development of the body or general feebleness of constitution, or those in which absence follows and continues unduly after some severe disease. In all these cases the treatment is to be indirect rather than direct. The absent function is to be restored by improving nutrition, by increasing bodily vigor, and by using every means to establish the general health on a firm basis. Measures for this purpose should be addressed to every particular of the habits, occupation, and surroundings of the patient. They do not differ from those of a general tonic course, but in some particulars a special influence may be exerted upon the function at fault. The clothing should be warm, especially about the pelvis and lower extremities, due care of the feet being impressed in proportion to the universal neglect shown by girls and women in regard to these important parts of the person. The diet should be of plain, wholesome, substantial food, and in many cases one of the lighter wines may be added to the principal meal of the day with decided advantage. Gymnastics may be prescribed, but outdoor life should be urged, with horseback riding as the very best mode of exercise for promoting the flow. A change of air and scene exerts a well-known and powerful influence in improving nutrition and modifying vital actions. It should be rather from the city to the country for these cases. Special advantages may be derived from a residence at the seaside on account of the beneficial effects of surf-bathing. A scientifically-conducted hydropathic establishment is very desirable for its regular hours, well-ordered diet, and treatment by baths and douches. Or a watering-place may be preferred where a chalybeate water may exert a special influence in addition to those of moderate indulgence in the gayety and amusement of such a place.

Inquiry as to school-life and educational work should never be omitted. The general mode of education of girls is faulty in the extreme. No attention is paid to the great change of puberty, which amounts to a revolution in the economy, and instead of aiding the vital forces drawn upon for effecting this change, they are still further depressed by sedentary life in close rooms or strongly urged in another direction. No two leading organs of the body can be pushed in development at the same time with impunity. There is no exception here: either the brain and nervous {189} system or the sexual organs will suffer. In this direction is often found a potent cause of all the forms of uterine derangement--a fact which cannot have escaped the observation of every physician. The writer has always urged an entire break in the school-life of girls of at least one year's duration at the time when signs of puberty begin to manifest themselves; and this period is too short rather than too long.

Tonics should supplement these regiminal measures. They may be hæmatic, stomachic, and nervous--either or all. There is a chain of diseased actions, and it may be attacked at any of its links. Iron stands at the head of the list. It is not only an hæmatic tonic, and in proper conditions a promoter of digestion, but decidedly promotes pelvic congestion, and has therefore an emmenagogue action. The forms at command are so numerous as to meet the requirements of any case or to satisfy any fancy. The standard preparations, as a rule, deserve the preference over more modern ones, in which efficacy is often sacrificed to elegance. Among the best are those which contain the remedy in a nascent state, as the compound mixture or the compound pills of iron of the Pharmacopoeia. Dialyzed iron, the tincture of the chloride, and the pyrophosphate are reliable, while the addition of manganese, as in the syrup of the iodide of iron and manganese, is believed by some to increase the efficacy. With iron may be combined nux vomica or strychnia and quinia. In large sections of our country malaria is a constantly-acting depressant of vital force, and the latter medicine may be given for a time with a free hand, and may be followed by or combined with arsenic to great advantage.

Constipation is almost universally present in women. It deserves especial consideration in treating all disorders of the sexual organs. When attention to habits and appropriate laxative food, as fruits, oatmeal, Indian meal, cracked wheat, and salads, do not suffice, resort must be had to enemata or drugs. Aloes has always had a reputation of special virtue in amenorrhoea which is doubtless well founded. In pill form it may be combined with any or all the other medicines. Pills of aloin, one-fifth or one-third of a grain, have the advantage of very small bulk.

Before considering more direct measures for establishing menstruation it may be well to recall to mind the two elements of the function--ovulation and the uterine flow. The first, the prime factor, we can not influence by any medicines nor by any mode of treatment except, perhaps, by electricity. Observation of animals shows that mere proximity of the male influences it plainly, but this only indicates a line along which we cannot prescribe. An opinion may, however, be asked in regard to the propriety or advisability of marriage for a woman who has never menstruated. In such case no advice should be given until after a thorough local examination, and its tenor will then be in accord with the condition of the organs. With such atresia or absence of organs as not to permit sexual intercourse marriage should be positively negatived. In such cases as those of partially-developed or absent uterus the facts should be laid before the parties interested and the decision referred to them. In the former class of cases some hopes of improvement may be entertained.

The second factor of menstruation, the flow, we can influence by such measures as cause a more or less intense pelvic congestion. The ovaries sharing in this congestion, it is not impossible that ovulation is in some {190} degree also promoted, but it can be only to a minor degree and when the ovaries are in a favorable condition. The uterus is the principal organ to be affected, and to it the most of these measures are addressed.

Direct treatment for the establishment of menstruation should be first of a character rather to solicit than to force the flow. These measures act best where, the general health having been restored, the flow does not appear, but the premonitory symptoms are present. Rest in bed, warmth to the pelvic region by poultices or other means, and hot drinks, are to be prescribed; among the latter infusions of pennyroyal, some of the mints, tansy, and cotton-root have a high domestic reputation and should be preferred. Hot pediluvia or hot sitz-baths, prolonged to twenty or thirty minutes, may be taken at bedtime. These may be rendered sufficiently stimulating to irritate the skin by the addition of mustard. More active measures are stimulating enemata and vaginal injections--for the former ten grains of aloes in mucilage, and for the latter liquor ammonia in milk, fluidrachm j-pint j, gradually increasing the strength to production of slight leucorrhoea. Both these have the endorsement of high authority.

Such measures should be used or plied more assiduously about the period, when that is known. During the interval a tonic course is almost always required, and a powerful local influence can be exerted by cold sitz-baths of brief duration, say one or two minutes, once daily, followed by vigorous rubbing with a coarse towel or a flesh-brush.

There are a few drugs known as emmenagogues from the reputation they have of promoting the menstrual flow. They all are powerful stimulants or irritants, and as they are also nearly all abortifacients, their reputation is probably well founded. Modern physiology, by exploding the doctrine of peccant humors to be carried off by menstruation, and by establishing the doctrine of ovulation, has greatly diminished their importance, while the varied conditions and causes of amenorrhoea already given show at a glance how restricted is the field for their administration. To give them when the anatomical conditions are unknown is blind work; to force a function relating to reproduction when the general system is struggling for existence is folly; and to goad diseased organs with special stimulants is certain to do injury. Now and then, however, special stimulants of this class and of the class next to be considered are required. There are some cases which fail to respond to the measures already detailed; there are others, generally recognized by writers, when menstruation is absent without any deterioration of health, known as cases of sexual atony or torpor; and others in which the flow fails or disappears earlier than the usual age. In these latter atrophy of the ovaries may be suspected, but cannot be verified during life, and treatment should be faithfully continued so long as there is reasonable probability of success. One case occurred in the experience of the writer in which the menses appeared occasionally during two years, each time apparently brought on by special stimulants, but ceased at thirty-two, the general health remaining excellent.