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J. A. (Joel Asaph) Allen.

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Potassium Pebmanganatb an Antidote fob Mobphinb. — Recent
despatches state that Dr. William Moore, of New York, claims
that when morphine is taken into the stomach and promptly fol-
lowed by the ingestion of a somewhat larger dose of potassium
permanganate, the latter drug causes the oxidation of the alkaloid,
rendering it harmless. To demonstrate the correctness of his
view, he recently, in the presence of a number of physicians,
swallowed three grains of morphine, taking immediately afterwards,
four grains of potassium permanganate ; and experienced no bad
effects. — Philadelphia PolycliniCy February 7, 1894.



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WHIPPLE: DTSMBNORBHEA. 46T

©rigiaaf (sommumcationA.

DYSMENORRHEA.^

By ELECTA B. WHIPPLE, A. M., M. D., Buffalo. N. Y.

With some hesitancy would tbe topic under conaideration be
brought before this body of learned, representative gynecologists,,
were it not true that disease and suffering, however trivial they
may appear in the light of science, demand recognition and must
ever receive attention from the conscientious physician. Hence^
no apology is required for presenting a subject trite as its litera-
ture is meager and broad as its pathology is obscure.

In view of this dearth in its literature and the many and
diverse theories held, the student must conclude that the etiology
of dysmenorrhea is but imperfectly understood. In considering
this important subject, whether in point of its etiology, prophy-
laxis, treatment, or citation of cases under observation, we would
emphasize excessive dysmenorrhea in contra-distinction to the-
pain, aching and lassitude ordinarily attending the menstrual
function.

It matters little to the suffering patient whether this affection
be primary or secondary in character, or whether it be a symptom
of some structural, pathological condition, or classed in the great
family of neuroses. But, under a nomenclature, varying as the*
pathology is conceived to be, the physician is called upon to treat
a neuralgic, inflammatory, congestive, membranous, obstructive,
or, more properly, an ovarian, uterine, or a constitutional dys
menorrhea.

WHO ARE THE SUFFEBEfLS?

This affection is not confined to the overworked, hysterical
shop-girl, standing upon her feet nearly from << sun to sun," nor
yet to the anemic, neurasthenic seamstress, who passes six days of
every week at the other horn of the dilemma, and rarely rises
from her chair in working hours. Nor can the society "bud,"
fritting her life away in late hours and rash exposures, be in this
exclusive, even from the ambitious school-girl, striving to be the
"star scholar" in her class, aikd thus furnishing a convenient
target at which anti-educationists may aim their luckless shots.
But the rosy-cheeked, romping, rollicking, carefree and easy

1. Reftd before the section on Obstetrics and Gynecology of the Buffalo Academy of
Medicine, ^oember SO, 1808.



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458 whipflb: dysmekobbhs^.

country girl, wall in every other respect, frequently saffers tor-
tares at each monthly epoch.

Again, dysmenorrhea is not only frequently present in the
sterile, but also in some parous women where no displacements
•exist, nor can any anatomical irregularities be discoyered, either
by microscopic or macroscopical examination.

ETIOLOGY.

That it is most essential to understand the etiology of a disease
before undertaking its treatment, goes without saying. Tet in
the literature of dysmenorrhea we find eminent gynecologists
averring that <' the relations between dysmenorrhea and its causes
Are very diverse and imperfectly understood, that no single theory
of its causation will apply in all cases, and that no nosological
system covers the ground satisfactorily from a clinical point of
view. Nevertheless, it is convenient to treat of the affection
under some of the various forms that we have assigned to it"

(a) Ovarian : That dysmenorrhea may be due to inflamed or
prolapsed ovaries is rational, especially when the excessive pain
referred to that region occurs from one week to ten days previous,
or following the menstrual epoch. Several cases of this kind come
vividly to the mind of the writer, to two only of which will refer-
ence be made.

Case I. — M. C, unmarried, age about 24, blonde, came under obser-
vation for relief from periodical suflfering. She was well developed, of
fine physique, stately carriage, full of energy and activity and not given
to '* sedentary laziness." About one week previous to each menstrua-
tion she was seized with severe lancinating pains, commencing in right
ovary and radiating through the entire pelvic region, until, as she
•expressed herself, she suffered from ** unbearable cramps,^* which
finally ceased and the menstrual period was passed in a most com-
fortable and painless manner.

Case II. — S. M., married, sterile, blonde, menstruation was unat-
tended with suffering, but, about one week after the period, she invari-
ably experienced intense and increasing pelvic pain, generally culmi-
nating in a prostrating headache.

{b) Uterine : What an array of young women and girls every
year present themselves not only to the specialist, but to the gen-
eral practitioner, for relief from distressing dysmenorrhea !

The etiology of many of these cases is confirmed by an exami-
nation, and under the proper treatment for congestions, ^isplace-



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WHIPPLE: DTSMBNOBBHEA. 459

ments of the ateras and stenosis of the cervical canal, they are
relieved.

Bat the greater part either have immanity for a considerable
length of time, pass from the notice of the physician who con-
siders them cared, and later the old trouble recars, or they drift
into the care of another, who under similar treatment may give
some relief, or entirely fail in the attempt.

For illustration, a few instances of this kind may be men-
tioned :

Cass I. — K. N., age 22, well developed, good color, bright, brown
eyes, in good general health, active, vivacious, a school-teacher, com-
plained of intense and increasing dysmenorrhea, so that she was com-
pelled to lie in bed for two or three days at each menstrual period.
Not only did she experience intense pain in back, hips and throughout
pelvis, so that morphia was liberally used, but incipient rigors, tempor-
ary contraction of facial muscles, rigidity and loss of consciousness
were present, when her physician resorted to the use of chloroform.
Uterus was in nearly normal position, dilatation of cervical canal gave
marked relief for a short time, but did not continue.

Case II. — M. E., unmarried, age 21, brunette, fine physique, plump,
a stenographer, suffered from dysmenorrhea, uterus was in normal posi-
tion, dilatation of cervical canal gave some improvement, but after a
few months usual pain returned.

Case III. — M. S.. unmarried, age 27, anemic, flow scanty, uterus
somewhat retroverted, but no benefit was experienced from dilatation
of cervix, which had been made by her physician.

Case IV. — M. W., unmarried, age 20, of a very nervous tempera-
ment, irritable, a stenographer. Each menstrual period was ushered in
with great suffering, flow profuse, lasting five or six days. Uterus was
retroverted but no discoverable stenosis, though her physician had
resorted to dilatation, which operation furnished not the least relief.

At the sixth annual meeting of the American Association of
Obstetricians and Gynecologists, held in June, 1893, in a most
interesting discussion following the reading of a paper on Dilata-
tion of the Cervix for Dysmenorrhea, one of the participants
stated that from his investigations, extending over a period of ten
years, where post-mortem examination of more than one thousand
ateri had been made, the condition of stenosis of the uterine canal,
in the lower segment, was one of the rarest conditions ever occur-
ring in that organ.

And what shall we say of those women who suflPer from
endometritis, displacements and numerous pelvic diseases, and yet



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400 WHIPPLE : DT8MBNOBBHBA.

pamf al menstraation is anknown to them, while women having nor-
mal ovaries, tubes and uteri suffer tortures at each menstrual period?
This brings us within the domain of

(c) Constitutional dysmenorrhea: Under this classification
may be found the anemic, chlorotic, neurasthenic, overworked and
underworked girls — all generally most unhygienic in their per-
sonal habits.

Many of these are of healthy parentage, endowed with a
heritage of robustness, and at the age of puberty possess every
apparent perquisite of health. The menstrual function is estab-
lished with but little pain, yet at each successive period becomes
more pronounced and aggravated until in a few years the recur-
rence becomes well-nigh unbearable.

It is not surprising to find this condition in women clerks,
standing all day upon their feet, laboring under more or less
excitement, wearing their clothing uncomfortably tight, going to
and from their work exposed to wet and cold, and evenings refrain-
ing from no pleasures that may conflict with a proper care of their
health. And we are not astonished that sewing women, stenog-
raphers, book-keepers, and those of sedentary habits, taking little
or no exercise in the open air, and denying themselves of sufficient,
good nourishing food are generally sufferers from dysmenorrhea.
Tet neither of these classes presenting themselves to the physi-
cian apparently receive one-half the solicitude that does the
school-girl. And when the mother consults the family physician
regarding any irregularities that menace the health of her fond
daughter, as if a confession of inability to relieve, it is quite popu-
lar to advise immediate removal from, school.

Prof. Gill Wylie, in an article published in the Am^erican Sys-
tem of Obstetrics and Genecology^ Vol. I., says: " It is a well-recog-
nized fact that dysmenorrhea is much more common among the
highly educated and well-to-do classes than among the laboring
classes." Further he says :

This is probably due to two causes: First, among the rich, the law
of survival of the fittest is interfered with; second, besides being
enfeebled by bad h^rgienic environments, the girls of the rich, as they
approach puberty, are compelled to expend all available force in intel-
lectual work at a time when the generative organs should be developed ;
even where a good constitution Is inherited and sufficient exercise,
food and sunlight are allowed to fairly well develop the muscular
system, if emotional and intellectual work is forced upon them during



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whipplb: dysmbnobbhba. 461

the period that the generative orcrans should be developed, or allowed
force to develop, they will be likely to suffer from dysmenorrhea due
to imperfect development of the generative organs.

It has been asserted that the poor, << being exempt from the
rigid laws and customs of civilization imposed upon the cultured
■and wealthy classes," are almost entirely free from local troubles.
But such is not the case, as the charity clinics in our hospitals
testify. And we know that many of the laboring women and
girls who have spent very little time in educational pursuits, but
having been subjected to prolonged bodily fatigue and heavy
menial work, suffer greatly from pelvic ailments.

Much ha8 been written upon this subject and some statistics
have been gathered, and yet they are so few and incomplete that
no logical conclusion can be deduced from them. No general,
systematic research has been made to determine in what way
physical growth and development, during the age of puberty, are
influenced by the mental work imposed by our schools. It does
not appear that the average American youth is in any immediate
danger of becoming a physical wreck on account of the difficult
<surriculi of study in the common schools. When we consider
that the average number of daily school hours for all the grades
is only about five, with intermissions, and the study periods will
not average more than one and one-half or two hours during the
sessions, and but one or two hours are devoted to study out of
school, it hardly seems plausible that intellectuality and culture
4ire acquired by our girls at the expense of physical development.
Dr. Mary Putnam Jacobi once pithily said:

It is in fact a matter of common observation that hysterical and
4inemic women, in whom disordered menstruation is most frequently
observed, are conspicuously destitute of habits implying either cerebral
or spinal activity ; that is, they neither think much, nor take much
physical exercise.

The health statistics of women college graduates, reported by a
special committee of the Association of Collegiate Alumnae,
together with statistical tables collated by the Massachusetts
Bureau of Statistics of Labor in 1885, gave in its summary of
results that the average age at which the girls began study was
^.64 years, at entering college 18.35 years, at graduating from
oollege 22.89 years. Furthermore, that the female graduates of
our colleges and universities do not seem to show, as the result of
their college studies and duties, any marked difference in general



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462 WHIPPLE : DTSMBNOBRHBA.

health from the average health likely to be reported by an equal
number of women engaged in other kinds of work, or, iii faot, of
women generally without regard to occupation followed. Why,
then, the very diverse conclusions arrived at by those who have
made but limited observations for special purposes? The small
amount of mental work imposed by the schools cannot in itself be
deleterious, but the evil lies in the methods of accomplishment.
The school-girl cannot be a society girl and maintain an ideal
standard of health. School work, supplemented by late hours,
midnight banquets, heating and suddenly cooling the surface of
the body, tight clothing, and going out of doors with feet incased
in paper-soled slippers, surely are not contributory to health and
do swell the statistics.

Neither can the school-girl, with impunity, lead a passive life
and, because of her preference, remain indoors during the school
intermissions, doing the most desultory studying, eating confec-
tionery, or an indigestible baker's lunch, when she should be in the
open air engaged in unrestrained exercise.

We concur with Prof. Wylie and others, that a great source of
dysmenorrhea is imperfect development of the generative organs,
which, however, we believe is due, not so much to the force
expended in intellectual work, but rather to a lack of systematic,,
hygienic exercise and a profound ignorance of the anatomy and
physiology of the pelvic and other organs of the human body.
How to remedy this alarmingly growing evil, and thus avert a
vast amount of suffering with its disastrous sequels, is a problem
requiring for its solution the thought of every progressive physi-
cian. And this brings us to the very threshold of

PROPHYLAXIS,

toward which we note the public trend. The keynote of prophy-
laxis was struck by Dr. Delancy Rochester, President of the Buf-
falo Academy of Medicine, in his scholarly and timely ^address
before that body, last June. Said he :

In our system of school education should be included an elementary
course in human physiology, in which every child should be instructed
before he or she has reached the age of fourteen or fifteen years.
The instructor in physiology should always be a thoroughly educated
physician.

This sentiment we most heartily indorse, and, furthermore, we
believe that daily hygienic exercise should be provided for every



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WHIPPLE: DTSMSKORBHBA. 463*

pupil in oar schools, ander the direction of an educated physician.
Then will the aphorism of Emerson no longer be forcibly true i
<< Society never adyances ; it recedes as fast on one side as it gains
on the other." Then the intellectual will not be gained at the
expense of the physical. Surely it is significant of this progres-
sive age when we find the public educator in unison with the
physician and working not only along lines but also in a physio-
logical manner, and directing the manual as well as /the mental
and moral training — the highest deyelopment of all being the
only true education.

We believe we are correct in the statement that in all the
grades of our city schools a smattering of physiology is now
taught, and in the High School, we are pleased to say, physiology
has for some time been taught by a physician. Also, in some of
the grades, at least, a feeble attempt is made to teach physical
culture, and we gladly note even these initial advances along the
lines of progressive thought and education. If the law for com-
pulsory education can be created and enforced, why not a law
for compulsory hygienic exercise in the schools ?

The family physician may be able to do something towarda
impressing the mother as to her duty in imparting to her offspring
whatever knowledge of physiology and hygiene she may possess.
But, in the majority of cases, there is a woeful ignorance, coupled
with that unaccountable diffidence existing between mother and
daughter in regard to those physiological subjects, where the
greatest frankness should be maintained. As a result, dysmenor-
rhea and other pelvic disord^s are inaugurated, which the girl
may never overcome. For these and obvious reasons, we believe
special instruction in our schools should be given by one thoroughly
competent, when greater heed will be taken and the health inter-
ests of those instructed be better subserved.

Also, the daily hygienic exercise, whether from the Swedish,.
Sargent, Emerson, or Delsarte systems, should be given under the
direction of a physician. Then will each pupil receive, at the
outset, a pl^sical examination, measurements be taken, and
strength tested, which tests, from time to time, will be repeated.
Directions can then be carried out in regard to the dress, and, at
least, five days in the week will the hygienic dress, suitable for
engaging in free exercise, be worn. Each will take the exercise
suited to her condition, and not only be taught to sit, to standi
to walk, and to carry herself correctly, but the abdominal



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464 WHIPPLE: DTSMBNOBBHBA.

4ind pelvic muscles will receive their share of attention and, we
believe, the great desideratum — proper development of the genera-
tive organs — will be better attained.

TRBATMBNT.

Since the purpose of this paper is the consideration of the
•etiology and prophylaxis, rather than the treatment, of dysmenor-
rhea, but brief reference will be made to the general therapeutics.

The suggestion of a vaginal examination is a great shock to
the sensitive, shrinking nature of the young girl, worn out with
suffering at each menstrual period, and terrified at t^he expectancy
-of a recurring one. Nor will the considerate physician exact this
until all probable and improbable remedies have been exhausted,
without success, in the endeavor to overcome the persistent dys-
menorrhea. If the sufferer is then unrelieved, more radical meas-
ures must be employed.

But the first step in the treatment of the married woman should
be a thorough examination for the purpose of detecting any exist-
ing displacements, stenosis of the cervical canal, or congestion of
the generative organs.

^ If displacements, flexions, stenoses, occlusions or polypi be
present, and in some diseased conditions of the ovaries, only oper-
ative measures will give relief.

In many cases due to inflammation of uterus and ovaries the
use of galvanism has given great satisfaction in completely over-
coming the existing dysmenorrhea.

If the patient be anemic or chlorotic, a tonic course of treat-
ment, with enforcement of strict hygiene, is indicated.

The habit which some young women and girls have formed of
<using alcohol and morphia — at first for relief from dysmenorrhea,
and finally for every ache and pain until they find the habit too
firmly fixed to be discontinued — should be denounced in no uncer-
tain terms by the family physician.

In an abstract of a paper by Thomas More Madden, M. D., read
before the International Medical Congress, Berlin, August, 1890,
he says:

Of all the ailments of female existence, few give rise to more per-
sistent suffering, or produce more disastrous effects on the general
health and even on the cerebro-nervous system, or on the moral consti-
tution of the patient than does well marked, obstructive dysmenorrhea.
The latter consequence is more especially evident in many cases of



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DOYLS: FRACTURES AND THBIR TREATMENT. 465

alcoholism* which, in women, may frequently be dated from their first
painful menstrual period, for the relief of which stimulants are too
often improperly administered and repeated in increasing doses until
finally, in many cases, the victim of dysmenorrhea! alcoholism becomes
an habitual and perhaps incurable drunkard.

In those cases characterized by a scanty menstruation, in which
no well-defined local or organic lesion can be foand, bat where a
neurotic or hysterical tendency prevails, the employment of drags
generally proves successful.

But a proper selection of remedies can be made only after a
careful study of each individual case, since that agent which
brings relief to one from distressing dysmenorrhea may be
utterly worthless for another, and what proves a success at one
time may be a failure at the next.

491 Porter Avenue.



OBSERVATIONS ON FRACTURES AND THEIR TREAT-

MENT.'

By GREGORY DOYLE, M. D., Syracuse, N. Y.

Ik no branch of surgery does experience prove a better friend
than in the treatment of fractures. Many of us, in our early days,
have issued forth from the threshold of our Alma MoUer with
bright new diplomas in our eager hands, and full confidence in
our undoubted ability to repair all forms of broken-up humanity;
a colic or a furuncle presented no more difficulties than the most
serious fracture. However, after a few surprises in the way of
disastrous results we were convinced of the importance of extreme
caution, careful attention and the assiduous study of each indi-
vidual case.

The young photographer, after having read up on his art,
thinks it only necessary to touch the button and take his chances
as to the results. After he has spoiled a number of plates and a
host of chemicals, it will perhaps dawn upon him that some
extended experience and practical knowledge would beget better
results and prevent many mistakes and much waste of good
material.

Some forms of fracture are difficult, and require most careful
examination to ascertain the exact condition of the injured parts.



1. Read before the Syracuse Academy of Medicine, February S, 18M.



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466 DOTLB : FRACTURES AND THEIR TREATMENT.

A good knowledge of anatomy is absolutely essential, for the
origin and attachment of muscles mast be taken into considera-
tion, as also the proximity of vessels and nerves to the injured
parts.

Tentative manipulation should be carefully and diligently
made until the exact character of the lesion is ascertained, for
if any part of the diagnosis is left to chance or guesswork, there
may be subsequent cause for regret. When examining a fracture,
all unnecessary suffering should be spared the patient. It is not
necessary to turn and twist the limb or grind the broken ends
together to get crepitation, as the unnatural outline of the injured
member with its abnormal flexibility will, in most cases, determine
the seat and nature of the fracture. The greatest gentleness should
be used, as the patient is supersensitive to pain, and rough hand-
ling may produce dangerous irritation to the muscles and nerves
and even rupture adjacent blood-vessels.

I remember seeing, in a distant city, a number of physicians
trying to differentiate between a dislocated hip and an intracap-
sular fracture of the femur, which to the practised eye is a very
easy matter. The patient was lying on a couch, surrounded by a
throng of solemn-faced wise-looking inquisitors ; each in his turn
took a tug and a twist out of the poor fellow's leg in his efforts to
make a diagnosis. This unnecessary and severe handling could
have been avoided had they recognized in the shortened limb and
everted foot a plain case of intracapsular fracture.

If any doubt should exist as to the real nature of the fracture,
anesthetics should be used, that a thorough and satisfactory exami-



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 46 of 78)