LETTER VI.. Of Menstruation.

OF MENSTRUATION.

Menorrhagia and Dysmenorrhea—Their Nature and Treatment.

In the present letter I propose giving you some thoughts concerning two other forms of disordered menstruation—I refer to menorrhagia—an immoderate flow of the menses, and dysmenorrhea, by which we understand painful or difficult menstruation. There are few subjects connected with health, which deserve more particular attention, or which are of greater interest to you, than these of which I am now to speak.

Menorrhagia, from two Greek words signifying the menses and to break out, implies, according to common acceptation, either an immoderate flow of the menses, or uterine hemorrhage, which is often a very different thing. It is generally characterized by pains in the loins, small of the back, and abdomen, similar to those of labor. There is always a preternatural flux of either blood or menstrual fluid from the vagina in what is termed menorrhagia.

Dr. Cullen reckoned six varieties of this disease.

1. Menorrhagia rubra, or bloody menorrhagia, from women neither with child nor in childbirth.

2. Menorrhagia alba, or white menorrhagia, which is, in other words, leucorrhea, fluor albus, or the whites.

3. Menorrhagia vitorium, arising from some local disease.

4. Menorrhagia lochialis, or lochial menorrhagia, from women after childbirth.

5. Menorrhagia abortus, or menorrhagia with abortion.

6. Menorrhagia nabothi, when there is a serous or watery discharge from the vagina in pregnant women.

I think it a better mode to treat of menorrhagia according to the original signification of the term, namely, an immoderate flow of the menses. I admit it must, from the nature of the case, be often difficult—indeed impossible—to determine whether a case belongs really to menorrhagia proper, or to hemorrhage from the womb. But the true indications of treatment would be the same in either case, so that a mistake in diagnosis would be of no manner of account in practice. I shall, then, speak of menorrhagia as a separate and distinct disease. I shall use the term simply as meaning an immoderate flow of the menses. Leucorrhea, hemorrhages, abortions, and the lochial discharge, will be spoken of separately. But I admit it must, after all, be a question, whether in all cases of immoderate flow of the menses, there is not actually hemorrhage. It is held by some, that the fluid, or discharge, in menstruation, is never capable of forming clots; in short, that it is in no sense common blood. But we know that in a great number of cases clots are formed. If it is, therefore, true, as some assert, that the menstrual fluid proper never coagulates, then, in all these cases to which I have referred, there must be hemorrhage. I am of the opinion, that the menstrual fluid is capable, in some cases at least, of coagulating like common blood. For all practical purposes then, it will be sufficient to understand by the term menorrhagia, all immoderate menstruation that does not actually amount to a plain and palpable hemorrhage.

Who are the persons that are most subject to menorrhagia? “Women who live indolently and indulge in stimulating articles; who use little or no exercise; who keep late hours; who dance inordinately; who are intemperate; who have borne many children; who have been subject to febrile affections; who have much leucorrhea; who are too prodigal of the joys of wedlock; who are advancing toward the non-menstrual period; who yield too readily to passions or emotions of the mind, are those,” says a distinguished author, “most subject to menorrhagia; to which may also be added, those women whose physical labors are too great, as well as those who have too little labor, are also subject to this disease.”

Menorrhagia, like amenorrhea, indicates a deteriorated state of the general health. A really healthy person can never have the disease, except, possibly, under some peculiar circumstance, for a single time. Real healthy persons, who have no natural impediments, always menstruate regularly.

Treatment.—The general indications of treatment will be inferred from the character of the disease. Do every thing that may be to fortify and invigorate the general health. Every thing that tends to this important object, acts indirectly to effect a cure. This is the only rational mode.

Daily and habitual bathing in water, tepid, cool, or cold, according to the patient’s strength, is a means of wonderful advantage in this disease. The fibers of the system are too lax, so to say; the vessels open too readily, and thus an unnatural discharge takes place. Imagine that you have walked a long way in a hot day: you find the veins of the hands and feet swollen, heated, and enlarged. The tonicity of their coats has become lessened. If a vein were opened under such circumstances, the flowing of blood would be much more free than ordinarily. Now if we wash these parts in which the veins are too much enlarged, we find that the water immediately strengthens them. The unnatural amount of blood is driven back, the vessels again assume their normal condition. Here we find an evidence of the tonic effects of cold water. Tepid water is also tonic, to a greater or less degree, because always cooling. It is on this tonic principle that water acts so favorably in excessive menstruation.

It is to be observed that in menorrhagia there is much less pain than in the opposite state, namely, deficient menstruation.

DYSMENORRHEA.

I next speak of dysmenorrhea, or painful, difficult, or laborious menstruation. This is not only a very common affection, but one of the most painful to which females are subject. Many a woman has spent almost her whole menstrual life with as much pain occurring at each menstrual period, as though labor itself had been passed through. What untold sufferings, alas! are women brought to endure in this disease. Can we for a moment suppose that it is in accordance with the designs of a benevolent Creator, that woman should thus suffer? I answer unhesitatingly, it cannot be. Neither can reason, analogy, or the facts of experience be brought to prove the contrary of my position.

The most prominent and distinctive feature of this disease is the pain. This is experienced mostly in the loins. There may also be pains in the uterus; pains, in short that resemble, both in character and severity, those of actual labor. These become so severe and agonizing, in some cases, as to cause the patient to faint. This affection is one in which not only great suffering is experienced, but is also often one of great obstinacy.

Dysmenorrhea may, for the sake of convenience, be divided into three species:

1. The inflammatory; which occurs in persons of a full, plethoric, and sanguine temperament.

2. The neuralgic; which occurs in persons of a highly excitable temperament, and of a delicate habit of body; and,

3. Where there is a mechanical difficulty to the passage of the menstrual fluid, as, for instance, a closed, or nearly-closed vagina, and a too small opening of the womb.

Those suffering from the first species of the disease are such as are generally too indolent in their habits, and partake too freely of rich and gross articles of food.

The second variety of the disease is often caused by the too free use of narcotics and stimulants, such as tea, coffee, opium, and, in some cases, tobacco; though, to woman’s credit, it is to be said this last article is not much used by them.

The third species may arise from some congenital impediment, or such as existed from birth. In the treatment of this last, mechanical or surgical means may, therefore, not unfrequently be resorted to with benefit.

Females, whether married or single, appear to be equally subject to this disease. In some cases, marriage appears to cure it; in other cases, it would seem that it caused it.

A change of air, such as leaving a city to reside in the country; or perhaps on the contrary, in some cases where persons remove from the country to the city, the affection ceases.

Effects of Pregnancy.—Pregnancy appears sometimes to break in upon the disease, and cure it; but it is far oftener true, that females who suffer from dysmenorrhea, are incapable of conceiving. Oftener, in this disease, there is a too scanty flow of the menstrual discharge. Sometimes, however, it commences with little or no discharge, but ends in a very copious gushing forth of the menses, which brings entire relief from the pain. “A membranous substance, or small coagulum, is discharged; if it be a membranous substance it will be found of unequal size, sometimes small, at other times large; and sometimes it resembles the cavity from which it has been expelled; at other times it will be broken into many fragments. After the expulsion of this substance, the woman enjoys ease, unless there be a fresh production, in which case it requires for its expulsion fresh contractile exertions of the uterus.” Dr. Denman regarded the secretion of this membranous substance as a mark of barrenness, and says that he never knew a female conceive, in whom it was formed. This rule, doubtless, often holds true, but not always, as observation proves.

Causes.—The causes of this disease are plainly the same, or very similar, to those which operate greatly to deteriorate the general health. “It would perhaps be very difficult,” says Dr. Dewees, “to assign all of its remote causes. The most common are the application of cold during the flow of the menses; taking cold after abortion; and in some instances it follows the beginning of marriage; but in other instances the causes are so hidden as not to be cognizable; the married and single are alike subject to it.”

Treatment.—Immense mischief has been done in this disease by the administration of powerful medicines. A disease so obstinate in its nature as often to call forth the greatest endeavors on the part of the physician to cure it, has been combated, in instances innumerable, by the most potent drugs. Nor are these poor suffering patients backward themselves to swallow any opiate, anodyne, or antispasmodic, however powerful and however harmful it might prove to the general system, if there is any prospect of obtaining present relief.

As this is one of the most painful affections to which human nature is subject, I will enter particularly into a consideration of the means to be employed to cure it. We may divide the treatment into two heads:

1. That which relates to the general health; and,

2. That which relates to the time in which pain is experienced.

As to the first of these considerations, all that I have said or can say in these letters respecting the means and modes of improving the general health and stamina of the system, should here be brought to mind. The second of these indications, however—that of relieving pain—I will endeavor to explain fully.

I must tell you that I have studied and practiced the healing art now a considerable number of years. I have endeavored to learn the truth in this important mission of healing the sick. I now, therefore, solemnly declare to you, that in the whole range of the medical art, so far as I have been able to learn it, I know of nothing that excites in my mind a more lively interest, or a more thankful feeling toward the Author of our being, than the adaptation of cold water as a means of relieving the pain and agony which often attend the menstrual period. There is, if I am a judge in this matter, nothing in the whole range of the materia medica, no, nor in all drug substances combined, that can at all compare with the power of this blessed element to assuage pain. But of this I shall speak more, presently.

As a remedy in painful menstruation, Dr. Good recommends “the advantages of traveling, change of air, and new stimulus given to both the mind and body by novelty of scene, novelty of company, amusing and animating conversation, and exercise of various kinds.” “With these,” continues this author, “may also be combined, in the intervals of the menstrual season, and particularly before the discharge has appeared, the use of cold, and especially of sea-bathing.”

Thus it appears that Dr. Good himself entertained the erroneous notion that cold bathing is a dangerous measure at the menstrual period. He observes, however, that “an unnecessary apprehension of catching cold by the employment of this powerful tonic has been entertained by many practitioners;” that with proper care he had never known it occasion this effect; and that it should only be relinquished when no reactive glow succeeds to the chill produced by immersion, and the system is hereby proved to be too debilitated for its use. But in the water-treatment, as you all know, we are not obliged to resort to cold immersion alone; the rubbing wet-sheet is a most excellent application in those cases where the reactive or calorific force is at a low ebb. We can also use tepid ablutions of various kinds with great advantage, under such circumstances—great, not only as regards the patient’s feelings of comfort and strength, but as to cleanliness, which is also an important consideration.

As to the second indication of treatment in these cases, suppose the pain is already upon you. You ask, “What are we to do?” I answer, there are many things, among which are the following:

The rubbing wet-sheet, with a good deal of rubbing and faithfully applied—many times in the whole day if you find need—is one of the best applications.

The wet girdle, likewise, should be kept constantly about the body, and changed as often as the pain requires. Wet compresses about the thighs and below the knees, or about the calves of the legs, are also useful.

The sitting-bath, cold, and sometimes alternating with warm, is also to be employed. If, at the same time, some one rubs the back well with the wet hand, the relief will be more speedy. In very bad cases, when the pain amounts really to a great agony, sitting in a wash-tub, with a couple of pails of cold water in it, at the same time having two or more persons to aid in rubbing the whole surface, if properly persevered in, must sooner or later quell the pain. Possibly, in some cases, it might require an hour or more to effect the desired object. If the patient becomes too much fatigued to continue the half-bath a long time, she can recline in a folded wet-sheet to rest herself, and then afterward proceed again to the bath. Frictions with the wet hand upon the surface, generally have great effect in assuaging pain in these cases.

The folded wet-sheet, that is, a common double sheet of linen, although cotton answers tolerably well, folded once each way, half of it being wet, and applied about the trunk of the body from the arms downward, is a very soothing application in these cases. Applied in this way, two thicknesses of the sheet next to the surface are wet, and the two outer thicknesses are dry. This is a very convenient application, and one great advantage in using a sheet in this way is, that we can open it in front of the body and rewet it, by sprinkling water upon it, without the patient being obliged to rise. If she is able to get up at the time of rewetting the sheet, it is better to do so; but if she is not, it can be done without. A patient may remain many hours in this folded sheet if there is need, a whole night, for example; but she should not allow herself to become too warm in it, as that would weaken the body. According to the season of the year, it should be rewet more or less often, and the patient should have more or less covering as she may feel a need.

The clyster is also a great help in subduing pain in the womb and back. The tepid, or lukewarm, as a general thing, answers best. We use, sometimes, gallons in succession, until the object is brought about.

The foot-bath is likewise a useful remedy. If the feet are cold, they should be put in warm water, the old-fashioned way; but if otherwise, cold answers the purpose best.

Now, it may occur to you, that this kind of treatment, which is so opposed to the old notions, is to be considered as a dangerous one. You know how afraid women are of cold under such circumstances, and how dangerous it is, in fact, to chill the body at certain times. But remember I am speaking of extreme cases of pain. Cold does not injure the body at such times; but, on the contrary, does a great amount of good. You know that if the discharge gets well started in these cases, the pain ceases. Now the cold, instead of checking the discharge, does actually help it to come. The pain, the undue heat in the uterus, the inflammation, as it might almost be styled, is the cause of the discharge not appearing. The application of cold puts a stop to this pain and undue heat, and thus the discharge is helped to come forward.

You will, then, perceive that cold, under circumstances of fatigue and exhaustion, must have a very different effect from what it does when the body is in great pain. In the former case it is highly dangerous; in the latter, highly useful.

But good as cold water is to relieve pain, do not, I beseech you, neglect the means of restoring the general health under these circumstances. It is very foolish, as well as inconsistent, to allow yourselves to go on in habits which your own better judgment must tell you, can only tend to make you worse at the menstrual period. Do not think, that because you have so good a remedy as cold water always at hand, that you can do as you like in regard to self-indulgence.