On the constitutional treatment of female diseases

Front matter

kirn

HB

S

Preface

The following observations on uterine and other female affections, have no claim to being a complete work on the diseases of women. I have, as far as possible, strictly adhered to the precise meaning of the title page, feeling convinced that if I had attempted to render the work complete, I should have incurred a more dangerous error by rendering the details incomplete.

I do not offer it as a class-book to those who are entering the medical profession, and whose studies must necessarily be chiefly, if not entirely, devoted to preparing themselves for their different examinations ; but I venture to offer it, more especially, to that large portion of my professional brethren, who, being engaged in general practice, have not been able to devote their special attention to a class of affections which, nevertheless, must frequently come under their notice.

The work is strictly practical; and I have endeavored throughout, as far as I could, to bear this in view. I have, therefore, devoted what may appear an unusual amount of consideration to the functional de-

X PREFACE.

rangements, particularly those of menstruation ; not only because they are affections of every-day occurrence, but because I am particularly anxious that their close connection with the general health, and its various conditions, especially as regards the chylopoietic viscera, should be thoroughly understood ; being convinced that on a right appreciation of this, depends not only their correct diagnosis, but also the principles of their successful treatment.

I have devoted separate chapters to the consideration of these subjects (Amenorrhcea, Dysmenorrhoea, &c), solely in deference to a long-established custom, which in former times was a necessity, when their nature and essential causes were imperfectly or erroneously understood, and which has been sanctioned by force of habit ; but I feel assured that my readers will agree writh me in the conviction that the time will come when these terms, as well as that of leucorrhoea, will no longer designate distinct affections, but will be classed with such symptoms as pain, rigors, expectoration, &c.

Neither do I consider that organic disease of the female generative organs is to stand as an exception to the importance of constitutional treatment; for I look upon it (to use an admirable expression of Dr. Latham's, on pulmonary consumption), as " no more than a fragment of a constitutional malady." The great additions which have been made to our pathological knowledge of late years, by means of microscopic and chemical research,

PREFACE. XI

fully warrant my application of the above expression to these diseases.

It may be objected that I have been guilty of a serious omission in not devoting a special chapter to the consideration of Metritis, which forms such an extensive subject in the French works ; but in answer I must confess that I have not seen inflammation of the womb in the unimpregnated state as a primary disease, although as an effect and symptom of other conditions it is common enough. And it has been my endeavor, whenever I have alluded to an inflammatory state of the uterus, to show that, in most cases, where the cause of it has been correctly ascertained and properly treated, this, like many other effects, will subside without trouble.

As further illustrations of the subject to which this work is devoted, I have occasionally referred to the series of cases which I have published in the Medical Times during the last twelve years.

Chapter I

Amenokehcea, 13 ; menstruation retarded by imperfect development, 13 ; symptoms, 14 ; chlorosis, 16 ; causes and treatment, 17 ; from congenital malformation, 24; from suppression, 31.

Chapter II

Dysmenorrhea, 33 ; functional and mechanical — functional, 36 ; varieties of, 41 : from derangement of the digestive organs, 41 ; from rheumatic-gouty habit, 42 ; of an hysterical, or neuralgic character, 43 ; inflammation of the os and cervix uteri, 45 ; from ovarian irritation, 47 ; mechanical, 50 ; treatment of, 53.

Chapter III

Menorrhagia, 55 ; varieties of, 57 ; active, 57 ; from gastro-bilious and rheumatic-gouty derangement, 62 ; from mucous irritation, 68 ; from ovarian irritation, 69 ; passive, 70 ; from displacement, &c, 75 •

CHAPTER IY.

Uterine and vaginal discharges, 80; connected with functional derangement, or arising from organic disease, 85 ; simple leucorrhoea, 85 ; from inflammation of the cervix uteri, 88 ; from inflammation of the vagina, 90 ; from organic disease, 91.

Ovarian tumors, 225 ; multilocular tumor, 226 ; symptoms of, 231 ; diagnosis, 233 ; constitutional treatment, 241 ; tapping, 242 ; rupture of the cyst, 245 ; ovariotomy, 247.

ON

DISEASES OF WOMEN

Chapter I. Amenorrhea

Amexorrhcea — absent or defective menstruation — may occur under a variety of circumstances, which will require a separate consideration.

It may have been retarded by imperfect development and general debility.

The catamenia may be defective or entirely wanting, from a congenital defect of those organs (ovaries, Fallopian tubes, and uterus) upon which this function essentially depends.

Although naturally secreted, they may have been retained, from some obstruction in the passages through which the discharge takes place.

The menstrual function may have been established naturally, and carried on regularly for some time, when it may become suspended or suppressed.

In the first case, when the appearance of the menses has been retarded by imperfect development, we find that the various changes in the system connected with puberty have not been effected, although the patient has attained an age at which they ought to have taken place. In other words, she is still a child, when she ought to have become a woman. Instead of having taken a fair amount of growth, the form becoming more expanded and robust, 2 and the breasts developed, the frame is delicate, the circulation feeble, the growth stunted. The group of changes which constitute puberty, have either not appeared, or have done so in a defective and imperfect manner, and among others the menstrual function has been delayed. It is a case of sluggish power and constitutional debility, and as such does not usually demand much active treatment: good air, plain nutritious food, early hours, active exercise, and attention to the bowels, will usually enable the system to gain sufficient strength to effect those various changes of growth and development on which the establishment of this periodic function depends.

When the powers of the system are more defective, we find this condition chiefly marked by the torpor and derangement of the chylopoietic viscera, and it is well known that where this is the case, the general tone and activity of the different functions become greatly depressed. The bowels are confined and unhealthy ; the liver torpid; the urine high colored, loaded, and probably scanty ; the skin dry and harsh, or cold, moist, and clammy ; the face pale and sallow ; the pulse feeble and easily excited, with occasional palpitation; the respiration short and imperfect; the tongue loaded with a thick yellow fur, through which the red elongated papillae frequently project — or it is pale, large, and flabby, and generally indented at its edges by the teeth ; the breath foul.

It is during this struggle of the system that we meet with a variety of affections which are very difficult to treat, such as violent headaches, different modifications of chorea, or even of epilepsy, eruptions of the skin, &c, which are evidently connected with and dependent upon the state of the patient's general health. When the powers of the system are sufficiently established to complete the process of puberty, the catamenia will probably appear, and these disorders usually cease, but I think it is a question whether they have ceased from the relief produced by the appearance of the discharge, or in consequence of the establishment of that amount of health and tone in the system which are necessary for the due

AMENORRHGSA. 15

performance of its various functions. Tt must not, "however, be supposed that in every case of tardy menstruation, the patient is diminutive in form and stunted in growth: this form of amenorrhoea is frequently seen in girls who have taken a rapid start in their growth at this time — who have, in fact, "overgrown themselves." The demand on the powers of the system, for the purpose of effecting the rapid increase of stature, renders it unable, for the time, to establish those functions of the uterus which otherwise ought to have commenced.

As the patient's strength increases, in like manner do those of passive congestion and fulness become more evident. A change is gradually creeping over her, and a new character of symptoms developing itself; — what, a little while ago, was a case of mere atony, debility, and torpor, now begins to exhibit, although imperfectly, evidences of congestive action. The circulation is stronger, but unequally distributed; the headaches, though probably not more severe, are accompanied with heat of head and flushing of the face, but it is rather of the purple color which characterizes passive congestion. Then she begins to feel pain of the back and loins, extending round the pelvis and down the thighs, with a sense of weight and stiffness. These local symptoms may be followed at once by the catamenial discharge, or may subside without any appearance, and return again in four, five, or more weeks, and this be repeated until the system has attained the necessary amount of strength to establish the discharge. These periodic exacerbations, or attempts of the system, are called Molimina Menstruationis.

The interval between the next appearance of the catamenia, will vary very considerably, depending in great measure on the patient's strength. As this improves, the intervals become shorter and more regular, until the function is fairly established.

When the powers of the system are more feeble, and therefore unequal to struggle against the depressing effects produced by the torpor and derangement of the digestive organs which attend this state, the appearance of the patient becomes still more unhealthy; there is a dark leaclen-colored ring beneath the eyes ; the pallor of the face assumes a peculiar sallow color, which, from its greenish tinge, has obtained for this condition the name of " green sickness," or Chlorosis. Secondary, as well as primary assimilation is defective — emaciation and debility advance at nearly an equal pace. There is a constant weariness and aching lassitude of the limbs, which incapacitate her from any exertion, and induce a disproportionate amount of fatigue, from which she appears but little relieved, even by a long rest. The sleep is disturbed and restless — sometimes unnaturally heavy. The bowels are obstinately costive — the evacuations very unhealthy; there is constant rumbling of flatus — the breath is fetid — she has a bad taste in her mouth — the tongue is foul — the powers of digestion almost suspended — the appetite fails, or is capricious, and frequently exhibits an abnormal perversity, in unnatural craving for things which are not articles of food, and which, under ordinary circumstances of health, would create a sensation of disgust; these are usually of an antacid absorbent nature, such as whiting, chalk, slate-pencils scraped into powder, cinders burnt to a white ash, &c; and, probably, in some cases, it is an instinctive longing to satisfy the uneasy sensations of a disordered stomach; in other cases, it is evidently connected with the morbid imaginations of a disordered mind, seeking unnatural gratification from what, in a state of health, would produce loathing. In either case, the patient is aware that she is doing wrong, and uses concealment in the endeavor to gratify her depraved appetite.

The circulation becomes more torpid and unhealthy; the nervous s}7stem is greatly depressed ; she feels incapable of mental or bodily exertion. Palpitation and breathlessness are excited by the slightest exercise, and are frequently accompanied by hysteric tears and sobbing. The depression of mind is most painful, and sometimes verges upon actual melancholia; indeed, the characters of the general health in melancholia have a strong analogy to the condition which I am now considering ; there is the same torpor of the digestive organs, the same

AMENOKRHCEA. 17

unhealthy condition of the primae vise, and the same loaded urine, usually with excess of urea, which is so constantly observed in melancholia.

The condition of the system is approaching to that of general cachexy; the feet swell, the eyelids after sleep are oedematous; she has a short barking stomach cough, which, from her debility and wretched appearance, easily gives rise to the suspicion of pulmonary mischief.

"The causes of this disease" (says Dr. Locock, in his admirable article on this subject, Encyclopaedia of Med) "may be shortly stated as all those which depress the vital powers — viz., a previous delicate and unhealthy childhood ; insufficient or improper food ; want of pure air and exercise; too close confinement to study in schools, or to labor in manufactories; depressing passions of the mind, &c."

The above enumeration of the causes of this form of amenorrhoea, viz., retarded menstruation, points out the indications which are to guide us in its prevention and treatment. They are, not to stimulate the uterus to greater activity by certain medicines, which, however dissimilar in their nature and modes of action, have been brought under one denomination — viz., Emmenagogues. Idiopathic amenorrhoea arising solely from suspended uterine function, without the concomitant circumstances just alluded to, is, to say the least, a very rare affection. The lapse of years has tended not only to confirm this opinion, but also the suspicion that where it has been supposed to exist, the fact has been attributable to the circumstance that the cause had not been rightly ascertained. A passage in Dr. W. Hunter's Lectures strikingly confirms this view: "Now, my opinion with regard to the management of the menses is, that you should pay no regard to them, but endeavor to put her to rights in other respects. If you cure the other disorders, you cure the irregularity of the menses, which is the consequence and not the cause of her complaints"

Dr. Marshall Hall, also, in his Commentary on the Diseases of Females, says: "Are the impeded functions of the uterus a cause of chlorosis, or are they the effect only?

2*

I imagine the latter. The state of the circulating fluids is probably deteriorated from defective digestion and assimilation, and this deteriorated condition of the blood probably becomes a cause, in its turn, of impaired vital energy, the heart and brain being imperfectly stimulated." The catamenial discharge may be considered as one among many other functions which indicate the state of the general health. These various functions are performed in an effective and regular manner when the powers of the system are fairly up to the mark. No function appears to be so subordinate to, and strikingly influenced by, the great processes of the system, as that of menstruation. The tone of the circulation, the healthy state of the digestive organs, &c, exert a remarkable influence upon it. The circumstance also, that when established, it acts as a periodic relief or safety valve to the system, shows that it may, in some measure, be regarded as an index of the tone, vigor, and power of a woman's health, and any deviation of the one will be attended with a corresponding fluctuation of the other. We are therefore justified in looking upon the functional derangements of menstruation, not as specific local affections, but as the local manifestations of certain conditions of the system. Our treatment ought, therefore, to be what is called " constitutional" or in other words, directed to the state of the general health; and, with certain few exceptions, the local treatment of these derangements must be secondary to the constitutional.

Amenorrhoea, like the other functional derangements of the uterine system, is, in fact, a symptom, as well as an effect, of general derangement; and it behooves the practitioner to look beyond the mere local affection, and carefully investigate the abnormal or defective actions of the sj^stem upon which it essentially depends. To use an admirable expression of Dr. Latham's upon the subject of Tubercle, it is but a fragment of a great constitutional malady.

In our treatment, therefore, of this form of amenorrhoea, our first object must be to restore the chylopoietic functions to a healthjr state. The medicines indicated will be of an alterative and laxative character, not only to clear the intestines of their unhealthy contents, but to rouse the liver to greater activity, and relieve the sluggish circulation and engorged vessels.

Equal parts of pil. hydrarg. and extr. coloc. comp., with or without extr. hyoscyami, should be given at night, and a draught of sodas potassio-tart., or potassae sulph. with manna and pulv. rhei, the following morning; and, if necessary, made more active by the addition of some tinct. sennae comp. The exhibition of saline medicines, during the day, is useful at this early stage, for they undoubtedly tend to purify and redden the dark unhealthy blood, and restore it to a healthier condition ; they promote the excretory functions, which we are anxious to rouse to greater activity; they diffuse a genial glow over the system, and lessen that weary sense of aching lassitude which is so exhausting and depressing to the patient.

If the papillae of the tongue be red and prominent, and she complains of tenderness at the epigastrium on pressure, a sinapism applied to this part gives great relief, not merely locally, but generally; it rouses the circulation, and seems to equalize its distribution over the frame, for the extremities become warmer and the headache is relieved, and the action of the medicines promoted. For a similar reason, the feet should be put into a hot foot-bath, up to the knees, every night, and, if hecessary, strengthened by the addition of%ome mustard.

The pills should be repeated every night, for three or four times, followed by the rhubarb draught the next morning, after which they should be given every other night for three more doses, and the morning draught repeated daily, unless its action be too brisk. By this time a large quantity of unhealthy fecal matter will probably have been removed. The complexion begins to lose its dusky sallow hue, and becomes clearer and brighter. The very expression of the patient's face is improved ; the apathetic listlessness, the nervous timidity have cleared away, and looks of intelligence and animation have taken the place of dulness and depression.

Early hours must be insisted on. She should sponge herself from head to foot every morning with cold or tepid water, according to the season of the year, and use active friction afterwards with a rough towel. The effects of these means will be still further improved by friction with a salt towel, when the skin is dry ; it produces an agreeable glow, and greatly increases the reaction of the cutaneous circulation, and is, moreover, an excuse for a little more exertion.

It is of the greatest importance that the extremities should be kept warm by active exercise, and that she should wear warm clothing, should the season of the year require it ; — indeed, unless it be actually summer weather, she should be clothed from head to foot in a warm elastic merino dress next the skin, and active exercise enjoined two or three times daily. It is a stupid and cruel error to take a young growing girl a long monotonous walk at a slow pace, as is the fashion in most girls' schools ; the fatigue is infinitely greater, and in all probability she returns with her extremities just as cold as when she set out. A brisk half-hour's walk, sufficiently quick to excite the respiration, will be, at first, as much as she is equal to; bvd this should be gradually lengthened as her strength increases ; she should also be encouraged to join in cheerful active games at home, such as battledore and shuttlecock, the circular swing, &c.

Horse exercise, if not used as a substitute for walking, is desirable, as*it rouses the circulation powerfully ; but we quite agree with the remarks of an eminent authority (Parry's Elements of Pathology and Therapeutics), that " it is usually a mere apology for the want of that exercise which Providence evidently intended that man should take by means of his own limbs, and not those of another." " Many persons, indeed, assert their inability to walk to any extent, or to employ any other active exertion— it heats, it fatigues, it pains them — it produces a thousand real or imaginary inconveniences; whereas the exercise of riding is in no degree fatiguing, and therefore must be infinitely more beneficial." (Vol. ii. §§31 and 33.)

Having occupied some days in steadily rousing the hepatic and intestinal secretions, and in clearing the bowels of their unhealthy contents, we may commence the use of tonics, and at once put her upon a course of steel medicine.

Two grains of ferri sulph. and two or three of quinine, with some extract of gentian, or hop, may be given twice or three times daily. The morning laxative should consist of the same dose of steel medicine, with from one to two drachms of magnesiae sulph., in the following form : —

R

-Ferri sulphatis .

gr. xvj

I

Magnesise sulph.

.

gj;

Acidi sulph., dil.

.

• Ei ;

Syrupi rhseados .

Aqua menthse pip.

.

. gvijss.

Fiat mistura, cujus

sn

mat cochl.

magn. ij,

primo

mane

M.

Twice a week she should repeat the blue pill, and thus keep up a steady action upon the liver and bowels ; or, if the stomach be irritable, the citrate of iron, or of iron and quinine in an effervescing form, will prove an agreeable and refreshing drink, by means of which the patient will be able to take a considerable quantity of steel medicine. Under a course of treatment of this character, the health usually improves, the vigor of the system returns to its natural standard, digestion and assimilation proceed with due activity, fresh and healthy blood is formed, the various symptoms which have been enumerated disappear, while those of health return, and with them we may expect the appearance of the menses. This will, however, depend upon how far the health and strength have been established ; and it must be borne in mind that, although the chylopoietic functions have been restored to a natural action, and the patient has in great measure regained her health, she may nevertheless not have attained a sufficient amount of strength to furnish this periodic effort and loss. It is desirable, therefore, to persevere in the above plan for some time ; for it will be self-evident, that where the powers of the system have been so depressed as to justify the term chlorosis, some months must probably elapse before it can have acquired sufficient strength to establish this secretion. It is the more necessary to bear this fact in mind, for an error is frequently committed in supposing that, the health being now restored, the absence of the catamenia must be the result of uterine torpor, and means to remedy this are put in force, when a little patience and perseverance in the above-mentioned plan of treatment would, in all probability, have entirely succeeded.

Generally speaking, it is now desirable that the patient should have change of air. A short residence in a mountainous district, or at the sea-shore, will frequently be of great service, and if the season of the year permit, a course of sea-bathing will be highly desirable. At any rate, she can bear the warm or tepid sea- water bath twice a week, and sponge herself thoroughly with sea-water (cold or tepid) every morning.

If, however, the catamenia do not appear after an apparently perfect restoration to health, it will be necessary to make a trial of those remedies which are considered to exert a specific effect on the uterine system.

A great variety of most discrepant remedies have been brought under the term Emmenagogue, a large proportion of which have either no action on the uterus at all, or only act upon it indirectly by their effects on other and neighboring organs. Thus, of the purgatives which have long enjoyed a reputation as emmenagogues, a considerable number act only by thoroughly clearing out the bowels, and thus restoring greater activity to the abdominal circulation; whereas others, as aloes, from acting chiefly on the lower bowels, and producing more or less disposition to hemorrhoidal congestion, indirectly rouse the uterus itself. Stimulant purgatives of this character, or even pure diffusible stimuli, have been used for this purpose as enemata into the rectum with good effect. Thus, ten grains of powdered aloes, suspended in mucilage and a small quantity of water, so as to be retained in the bowel more easily, has been found by Prof. Schonlein, of Berlin, to have a powerful effect in exciting uterine action and bringing on the menstrual secretion. And ten drops of liquor ammoniae in a little warm milk, has

AMEXORRHCEA. 23

been also used by Dr. Locock, for the same purpose, "with, equal success. Local stimulants applied to the breasts (as sinapisms, &c.) are known to act powerfully on the uterus through their sympathy with this organ, and induce the catamenia when other means had failed.

The various preparations of iron promote the menstrual secretion solely by acting as tonics, and by restoring the healthy condition of the circulation. Combined with laxatives, they also increase the contractile tone of the intestinal canal, diminish its calibre, and thereby the bulk which it occupies in the abdominal cavity ; pressure is taken off the abdominal circulation, and the supply of blood to the uterus is rendered more active and free.

The emmenao"02Tie action of cantharides is more doubt-

DO"

ful ; it is well known to exert a powerfully stimulant effect upon the bladder, and is thus capable of acting indirectly on the uterus. But the observations of the late Dr. Dewees, of Philadelphia, as to its effect in leucorrho^a, render it not improbable that it is also capable of acting directly upon the uterus.

The savine is a violent stimulant, and has a powerful effect in exciting hemorrhagic action: and certainly in cases where it has been given with a criminal intent to excite abortion, it appears to have acted directly on the uterus, and to be strictly an emmenagogue.

The two most valuable emmenagogues which we possess, and which exert a specific action upon the uterus, are the preparations of iodine, and the secale cornutum. The iodide of iron is perhaps the best form for administering iodine to obtain its emmenagogue effects, and may be given in the form of pill or syrup two or three times daily. The secale cornutum is best given in the fresh powder, suspended in water with a little mucilage. But I would again earnestly impress on the minds of my readers, that medicines of this sort are very rarely needed in the treatment of amenorrhoea ; the case either requiring a little more patience and perseverance in the treatment previously recommended, or depending on other conditions, shortly to be considered, and which are less under our control.

We every now and then meet with, cases where the health, although good, is feeble; the patient is well grown and fully formed, and yet the powers of the system so feeble and torpid (especially of the circulation), that menstruation is not established until several years later than the ordinary period, and then in a scanty, imperfect manner. In some it occurs chiefly in the summer months, and is absent during the winter, as is seen among the females of the arctic regions; it also generally ceases some years before the usual time. The case is evidently one of deficient power, and the use of emmenagogues, either to induce or maintain the periodical discharge, would here be injurious, as it would only be stimulating the system to make efforts for which it is unfitted.1

The next form of amenorrhoea — viz., where it depends on " congenital defect of the organs on which this function essentially depends" — is fortunately of rare occurrence, for it admits of little or no treatment. Instead of the form becoming more rounded, the breasts more prominent, the figure assumes a gaunt and masculine character; the growth is unusually vigorous, the frame muscular, the shoulders broad and square, the hands and feet large and long, the features coarse. A quantity of hair sometimes covers the upper lip, and occasionally there is a complete beard, as in the male. The mammae are small and defective. If the patient has passed the ordinary age of puberty without any appearance of the catamenia, and without any of those symptoms which have been called the Molimina Menstruation™, and which indicate an effort of the system to establish the discharge — if, also, she suffers from no inconvenience from this state of amenorrhoea, the case probably depends upon a defective condition, or entire absence, of the ovaries and uterus. The masculine expression and figure vary considerably in these cases; in some they are scarcely perceptible, in others they exist to a very marked degree. In some the breasts are fairly developed, and perhaps slight menstrual efforts have been occasionally manifested, but they have

1 See case of Mrs. S., Med, Times, July 5, 1851.

AMKNOEEHCEA. 25

given "her little or no inconvenience, and have disappeared again ; whereas, in others, the mammary glands are scarcely developed at all.

The usual characters of this defective state, as far as can be ascertained by examination during life, are that we find a small, narrow vagina, much shorter than usual, and generally without any trace of os uteri, or a mere thickening where it ought to have been, and no traces of a uterus beyond. There are, of course, many other modifications of these congenital defects, but they properly belong to the next species of amenorrhoea. I will only observe, in concluding this subject, the rather remarkable fact that, in the majority of these cases which have come under my notice, the patients were married.