Vicarious Menstruation. H. G. LANDIS, A.M., M.D. Reprint from the Cincinnati Lancet and Clinic, February atft'L, 1880. Vicarious Menstruation. By H. G. LANDIS, A.M., M.D., Prof, of Obstetrics in Starling Medical College.1 At a recent meeting of the Franklin Co. Medical Society, Dr. S. Loving reported a case of vicarious, or in that instance it might better be termed, supplemental men- struation, in which a woman had a discharge of blood from the nipples at or near the menstrual periods. Iq view of the fact that the text-books in common use, such as Leishman and Playfair in Obstetrics, Thomas and Emmett in Gynaecology, Flint and Da Costa in general practice, mention the subject with a brevity calculated to de- tract from its importance, and also fail to give any instances of its occurrence by way of illustration, I have thought it well to col- late a number of cases already recorded in our didactic and periodical literature with a few unpublished ones. From their study we may the better appreciate the import- ance and nature of this curious disorder. The occurrence of vicarious menstruation was well known to the ancients, who, fol- lowing the views of Aristotle concerning the menstrual flow, saw nothing very remark- able in the phenomenon. Hippocrates2 alludes to it without comment and quite as a matter of course. Aretaeus,3 in speaking of hemoptysis, says : “This mode of bring- ing up blood is common with women who have not their monthly purgation, and ap- pears at the periods of the purgation and stops during the interval between them, and if the woman is not cured, the dis- charge upwards of blood will revert for many periods and also in certain cases the vessels burst from fulness.” This notion of an outlet of some sort as necessary to re- lieve a monthly plethora, was evidently be- fore Ambroise Pare when he said,4 “In my wife when she was a maid, the men- strual matter was excluded and purged by the nostrils. The wife of Peter Feure of Casteaudun was purged of her menstrual matter by the dugs everie moneth, and in such abundance that scarce three or four cloaths were able to drie it and suck it up. We may also see in these words a sugges- tion of the belief that the menstrual blood is a true secretion of the uterus, which was advocated by Haller and John Hunter. The gradual change of doctrine from a be- lief in the general character of the men- strual phenomena to one in their special connection with the uterus, from a belief that it was only blood the escape of which relieved a monthly recurring plethora to a belief that the womb excreted or secreted a peccant humor, makes a curious change in the manner of reporting cases of vicarious menstruation. Thus Denman,1 translating almost literally from DeGraf, says: “When women are deprived of the common uterine discharge, they are sometimes liable to periodical emissions of blood from the nose, lungs, ears, eyes, breasts, navel, and almost every part of .the body.” But he adds, “These, which are very rare, have been deemed deviations of the menses, and com- municated with the most scrupulous exact- ness, as if some great advantage was to be obtained from our knowledge of them.” From this and what follows it appears likely that his opinions concerning its rarety and unimportance were in part influenced by the difficulty in accounting for it and of reconciling the facts with his theory. Hence our astonishment at finding a few pages on, this remark, which may serve as a warning to us. “To unsophisticated ob- servation, and to a mere relation of facts, or the inferences plainly to be deduced from them, men are unwilling to submit, as the powers of the imagination by such proceed- ing would be checked or suppressed, the want of understanding concealed and the parade of learning lost.” 2 A like frame of mind may account for West 3 dismissing such cases curtly as “medical wonders; ” but we may thank him for putting on record the fact that the vicarious discharge may be associated with menorrhagia. The ovular theory ot menstruation gave a new aspect to these cases and the latest doctrines still another. With what new doctrines the womb of the future is pregnant we cannot tell, but having thus briefly noted the pro- gress of opinions and the different notions of its frequency will proceed to the more practical method of reciting cases and draw- t. Read before the Franklin County and Central Ohio Medical Societies, and published at their request. 2. Aphor. V. 33. 3' Ed. Sydenham Society, p. 267. , 4. Opera, page 638. 1. Midwife, Frances’ Edition, page 174. 2. Ibid, page 178. 3. On Women, American Edition, 1861. 4 VIC A RIO US MENS TR UA TION. ing “inferences plainly to be deduced from them,” as the usually judicious Denman re- marks. Churchill gives the subjoined references 1 and reports some cases. In Dr. Law’s practice a girl aet. 21, previously in bad health, missed a menstrual period and had a hemorrhage from the ears. Vomiting next occurred and finally diarrhoea, after which her health was improved and men- struation became normal. In Dr. Dunlap’s practice a fatal case occurred, no less than six quarts of blood being lost from the gums at one period. He had himself seen a case in which profuse salivation seemed to take the place of the menses, and quotes Liebold as having seen a similar one. Blundell2 reports a case in which the flow came from the hand for three successive periods, preceded by a throbbing in the radial artery. Bedford :i records the account of three young girls, menstruating respect- ively from the umbilicus, by epistaxis and by hcematemesis. Ash well4 reports a case of vicarious hemorrhage from the ear, one from the breast, and one in whom a profuse leucorrlioea took the place of the flow for a number of periods. He also alludes to the fact that the vicarious flow is sometimes discharged gradually and sometimes in gushes. Biittner of Halberstadt5 records a case of habitual menstruation from the breast. The flow continued five or six days, becoming white and mucilagnious to- wards the close. A like case is reported by P. Megnet,6 in which a girl set. 17, men- struated from the breasts a whole year at the usual periods; menstruation then took place from the natural channels but irreg- ularly. In the practice of 1 )r. Atlee7 of Lan- caster, a case occurred in which menstru- ation was regular and plentiful, but was supplemented by hemorrhage from the stomach and nipples. This account is ac- companied by that of a negro woman who menstruated from the mouth and seems to have been cured by the removal of defect- tive teeth and the removal of fungousgums. A mere list of cases might be indefinitely prolonged, but it will be more instructive to group them as illustrating special points. 1. The vicarious discharge may occur only at the beginning or close of the woman’s menstrual life; it may also appear at any time for .one or more successive periods, or it may occur as the only mode throughout life, as in a case quoted by Watson from Pinel • nor need it interfere at all with con- ception. Obermeier 1 relates a case in which a girl menstruated only by expistaxis, except for one day in her fifteenth year. Conception occurred nine years after the beginning of puberty, causing a cessation of the periodical epistaxis, which returned six weeks after her delivery at full term. A second pregnancy in progress at the date of the report also stopped the flow. Barrett2 also reports a case in which the rectum was the sole seat of the discharge, which was stopped by pregnancy and reappeared fif- teen months after delivery, to be again checked by a second and later by a third pregnancy. During the discussion of this subject at the Franklin County Medical Society, Drs. Loving and Denig each re- ported a case in which leucorrhoea was the only exponent of menstruation until after the birth of four or five children. 2. The same tissues may not be theinvari- able locality in any individual. Dewees3 quotes from Gardiner the case of a girl who menstruated regularly for six months “from little wounds in the leg occasioned by the breaking of small vesicles.” For the next year the same performance was enacted upon the arm. For six months she men- struated from a whitlow and chap upon the left thumb. An attack of facial erysip- elas left some opening upon the face from which she menstruated for two years, re- turning to the left thumb for a season. Va- riety being the spice of life, the navel next officiated for five months until an accident to the internal malleolus of the left ankle relieved it for two months. When not menstruating from any deterimate spot she discharged blood by epistaxis or haemate- mesis, preceded by headache and giddiness. 3. From the so-called sympathy between the uterus and the breasts, we would natu- rally expect the latter to be the elective seat of the hemorrhage. Astley Cooper, 4 .1 [Capuron, Malad. d femmes, p. 120. Astruc, v. 1. p.158. Haller’s Physiol. Liebold’s Krauenzimmerkn, vol, i, P- 338- Astbury Edin. M. and S. Journal, vol. 17, p. 307. Edin. Med. Essays, vol. 3, p. 341. Hamelton, Med. Commnr.,vol. 11, p. 337. Mem. of Med. Soc., vol. 3, P5. 502. Davis, Obst. Med. vol. 1, p. 242, Lacock, Cyclop, of Pract. Med., vol. 1, p. 71. Med. Gazette, July 29, 1837. Guy’s H. Reports, No. 5, p. 156. Am. Med. Journal, April, 1850. Edin. Month. Journ., Oct., 1850. Journ. de Med. et Chirurg., Feb., 1850.] 2. Midwifery, ped., 1840. 3. Obstetric Clinique, p. 80. 4. Dis. of Women, 1845. •5. Lancet, Dec. 18, 1824. 6. N. Y. Med. Journal, 1872. 7. Ohio M. and S. Journal, 1849. 1. Phila. Medical Times, Nov. g, 72 2. N. Y. Med. Journ., 1876. 3. On Women, 1837. * 4. Philadelphia, 1845, page 61. VIC A RIO US MENS TR UA TION. 5 Hirkett 1 and Gross, ■ but mirabile dictu not Velpeau, describe a form of apoplexy or ecchymosis of the breast occurring usually a few days before the menstrual period. The first records four cases; in one of which blood escaped from the nipples. Puech,11 however, in analyzing number of cases, found that the order of was, from the stomach, 32, breasts 25, lungs 25, and from the nose 18. In 183 cases the menses were absent, and in 15 present. A most inconvenient and un- sightly location is upon the lips, as in a case reported by Parvin4 and illustrated by photographs of the girl before and during its continuance. The swelling and dis- coloration would indeed dispose such a one to separate herself from the congregation until the days of her purefying were accom- plished. 4. The exciting cause of vicarious men- struation does not seem to be at present within our ken, and probably not the same in each instance. Caro5 reports a case of menstruation from the gums following an attack of malarial fever, which, in the opin- ion of Dr. Isaac Taylor, “ predisposes to this event. A previous condition of ill- health is frequently mentioned in the report of these cases. Goodman 1 gives cases of vascular naevi as the seat of hemorrhage, in one of which he predicted before the time of puberty that the patient would menstru- ate from a naevus. On the other hand may be cited a case observed by our friend Dr. J. H. Pooley. A young married wo- man had upon her lower lip a naveus as large as the end of the thumb. During childhood it existed only as a telangiectatic spot or “red spider,” scarcely noticeable. At the age of puberty it became a little ele- vated but was prominent only at the men- strual periods. But in the four months of pregnancy it had attained the size noted above. Disease of the womb is sometimes coexistent, perhaps always in some form, though Peuch specifies that in his cases the genital organs were healthy as a rule. Lecointe of Eu,* records the case of a girl tet. twenty-nine years, who had never menstruated, but had a periodical discharge of membranous casts from the uterus, blad- tier, stomach and rectum. After some time a sanguineous flux from the ear was established. Other cases of membranous exfoliations from the uterus'are on record, but the degree of uterine disease when pre- sent is usually spoken of as slight. It ap- pears to be sometimes hereditary. Laycock1 mentions among other cases two of “san- guineous ephidrosis of the feet, occurring only during the menstrual period when any extra exercise was taken. The subject of these were a mother and a daughter, both of very hysterical habit.” Barnes'2 records the case of a young lady set. twenty-four, with vicarious haematemesis, sometimes dangerously profuse. “A sister, when sixteen, who had hitherto menstruated scantily had haematemesis at her periods. A brother aet. five, died of epistaxis after purpura. The father died of epistaxis at fifty-six; caused, his wife says, by intem- perance, which produced epilepsy. When- ever he had a fit, he had hemorrhage.” 5. The possession of a womb does not seem to be a necessary factor in menstru- ation. Congenital absence of the womb in a case of vicarious menstruation was found in a case observed by Cazeaux.3 This woman, aet. twenty-one, had an im- perfect development of the external organs as well and no hair upon the pubes. The flow came from the vagina. A case oc- curred in the Pennsylvania Hospital 4 in 1873, in which the most careful examina- tion could not discover a uterus and in which the ovaries were also rudimentary in size. The patient was twenty-two years old and had menstruated by epistaxis and other hemorrhages since her fourteenth year. At the menstrual molimen she suf- fered from headache and pelvic distress which was on several occasions relieved by the application of leeches to the thighs and abdomen. Barnes5 gives an account of a case in which the woman had menstruated several times from the nose and gums and then died from pulmonary congestion and oedema. The autopsy showed a complete absence of the uterus, the ovaries being well developed and containing a recent “false corpus luteum.” Menstruation from the vagina or cicatrix has also occurred after the ablation of the uterus; thus, W. G. Drake'1 reports the removal of the entire 1. Holme’s Surgery. 2. First Edition, volume 1, page 1061. 8. Gazette de Hospitaux, April 21, ’63. 4. Proc. American Gyn. Society, 1876. 4. New York Medical Record, 1878. 6. Ibid. 7. American Journal Obstetrics, October 1878 8. Lancet, 1851. 1. Nervous Diseases of Women, 1840, page 220. 2. Diseases of Women, page 181. 3. Midwife, 5th Edition, page 508. 4. Philadelphia Medical Times, October 24, 1874. 5. Op. Cit.; page 182. 6. Atlanta Medical Journal, Aug., 1875. 6 VIC A RIO US MENS TR UA TION. uterus and Fallopian tubes from a woman who menstruated regularly afterwards from the vagi«a. And that there may be no doubt as to the non-essential part fulfilled by the womb, we have accounts in the older writers of a monthly flow of blood from the urethra and rectum of some men. 1 Such a case is reported by Townsend,2 of a male; who, for thirty-nine years, had a sanguineous flow every lunar month, unac- companied by pain. Dr. N. O. King :i re- ports the case of a man set. twenty-two years, with a flow from the sebaceous glands behind the corona glandis. It was sanguineous, homogenous and thick, flowed at each period to the extent of one or two ounces, and lasted from three to six days. It had continued periodically for three years at the date of record. 6. The practical aspect of the subject is illustrated by the liability of making an er- roneous diagnosis of a given case. A. J Stone 4 reports the case of a woman who had vicarious menstruation from the lungs, coming on several months after child-birth. She passed through the .hands of a number of physicians who made the diagnosis of tubercular consumption and subjected her to much unnecessary medication. She was finally cured by scarification of the uterus and topical applications to the endometrium. My friend, Dr. T. C. Hoover, informs me of a woman seen by him, who menstruated vicariously by the rectum ; but having tor- mina and tenesmus was at first supposed to be suffering from dysentery and treated ac- cordingly. She had also a scanty flow from the uterus, and was cured by building up the general health. J. Burns5 quotes Bail- lou (de Virgin., et Mulier. Morbis, vol. 4, p. 75) as follows: “In young girls and elderly women when the menses are ob- structed or irregular, the spleen sometimes swells; and subsides again when the menses become regular.” Besides the physiologi- cal interest of this observation, it suggests the possibility of such an occurence mis- leading the practitioner if great attention was not paid to the history of the case. 7. The results of treatment, some of which have been already noted, are inter- esting. In the Lancet for 1844, besides the report of a case in which an arm be- came swollen at five successive menstrual periods, is one in which the vicarious dis- charge took place from a diseased finger. Amputation was resorted to; the wound healed easily, but there was great determi- nation of the blood to the forearm for sev- eral months after. Critchett, 1 in an essay on ulcers of the lower extremity, speaks of vicarious menstruation from them and com- bats what he says is the prevailing doctrine, viz. : “Restore the healthy function of the uterus and the ulcer will heal.” He be- lieves in the converse proposition, “Heal the ulcer and the uterine function will be restored.” This view is not borne out by the majority of cases in which the treatment is mentioned, and if we regard the vicarious flow in the light of a safety-valve, it is prob- able that a transfer to a more dangerous lo- cality might occur if such an ulcer were prematurely suppressed before the natural channel was restored. 8. Before drawing conclusions from this record of cases, I will add for the sake of completeness, that menstruation has oc- curred after the removal of the ovaries. Goodman - collected in 1875, twenty-seven cases of removal of both ovaries, in thirteen of which the patient continued to menstru- ate regularly. In one it was increased, in one diminished, and in several, irregular sanguineous flows, not counted as menstru- ation, occurred. A. Reeves Jackson,3 in an excellent paper upon the doctrines con- cerning menstruations, gives other instances of menstruation without ovaries. We may now begin to accommodate Dr. Denman by drawing inferences plainly to be deduced from these cases. 1. Vicarious menstruation is not very uncommon, and is, therefore, an important consideration in diagnosis. When females are the subject of hemorrhage from any cause and more especially when the cause is not at once apparent, the menstrual his- tory of the woman should be inquired into with care; and when occurring at the age of puberty, an examination of the genitals would not be amiss. 2. The vicarious or supplementary flow may proceed from any part of the body whatever. The election of the Schneid- erian mucous membrane, the lungs and ulcers or wounds in preference to other situations, as well as the anaemia or other- wise deficient condition of the patient’s 1. Laycock, op. cit., page 79. 2. American Medical Recorder, vol 3. 3. American Journal Med. Scien., April, 1867. 4. Northwestern Med. and Surg. Journal, Mar. 1872. 5. Midwife, 1810. 1. Lancet; 1848. \ 2. Rich, and Louisv. Medical Journal, Dec , 1875. 3. American Journal Obstetrics, October, 1876. V/CA K10 US t\tF.NS TR UA TION. 7 health previously, would lead us to infer that originally weak, or weakened and tone- less capillaries were the proximate cause of the phenomenon ; especially when associ- ated with a thickened or tough and resisting mucous membrane. The researches of Engelmann, Williams and others as to the change which takes place in the mucous membrane of the uterus during menstrua- ation, show us that some time is required before the capillaries give way. In fact, since the uterine mucous membrane is the thickest in the body, it is not at all surpris- ing that resistance to generally increased vascular tension should be weaker in other parts of the body. If it were not for the prolonged venous stasis in the uterus at this time and the exfoliative changes which this induces in this membrane, it would be the last tissue to furnish a hemorrhage in- stead of the customary one. 3. We should not lose sight of the fact that in cases of suppression of the natural discharge its occurrence in a suitable lo- cality is a beneficial circumstance; often re- lieving grave symptoms of internal organs and preventing serious disease. 4. From the fact that it is not constant in its point of flow, and from the dangers attending menstruation from such organs as the lungs and eyes, attempts should al- ways be made to establish or restore the flow from the uterus as a more suitable, convenient and natural channel. To this end applications to the endometrium are indicated. Chromic and carbolic acids have been employed with good effect, re- sulting in the exfoliation of casts or shreds of the uterine mucous membrane and prob- ably in its renewal in a better condition. Scarification of the cervix and leeches ap- plied to the groin or perineum have also proved serviceable, mainly as a palliative measure. The general health should also be promoted by remedies calculated to im- prove nutrition and by tonics. The occurrence of the hemorrhage has been observed to precede the usual period of the flow by several days, notably in the case of the breasts. > This clinical demon- stration of the increase in general vascular tension which precedes the appearance of the uterine flow corroborates the researches of Barnes, Goodman and others upon this point, and is of practical importance. In surgical operations, especially near the genitals, when undertaken a few days be- fore menstruation, alarming hemorrhages from the divided tissues has occurred. This should lead us to be cautious about the time selected for operations upon wo- men, lest if a menstrual period be immi- nent the flow may be diverted from the uterus and escape from the readier outlet made by the surgeon’s knife. This was first suggested and a case in point narrated by Goodwin, in his instructive paper upon the cyclical theory of menstruation,1 in which he removed a small tumor from the neighborhood of the genitals, six days be- fore a menstrual period, and in which a severe hemorrhage took place within twenty- four hours. Dr. J. H. Pooley at the meeting referred to above, reported a case in which he had operated for fistula in ano in a young woman just a few days before an expected period. A small cutaneous artery was cut, which stopped bleeding be- fore the operation was ended. In the middle of the night it began to bleed copi- ously and was tied. A few hours after, profuse hemorrhage occurred by general oozing from the cut surfaces which was not restrained until the patient had become pallid to the lips and manifested symptoms of syncope when attempting to arise. It is interesting to add that the expected period did not appear, for as the patient remarked, “Where was the blood to come from?” These are the practical lessons suggested by these cases, but they are further instructive by the light thrown upon the nature of normal menstruation as well. 6. They direct our attention away from the pelvic organs as the essential factors in menstruation to the general system, and suggests to us that it is a constitutional rather than an entirely local phenomenon. For, i st, the womb is clearly unnecessary in the origination or maintenance of men- struation, since the latter occurs from other tissues and when the womb is congenitally absent or has been removed. 2d. Though no one will dispute the importance of the connection between the ovaries and men- struation, it is equally evident that they too are not the sole esential element in the function. For menstruation has occurred when they were rudimentary, diseased, or entirely removed. (For particulars see authors already quoted, Kesteven, Sinedy and Hausmaun and current literature in general upon the subject.) And in one case at least, both the uterus and ovaries were i. Am. Journal Obstetrics, volume q. 8 V[CAR TO US MENS TR UA TION. removed, without influence upon menstru- ation. In the presence of these facts, several courses of reasoning are before us. We may imitate the ostrich (not to say Ananias), and say with Leishman, 1 that there is “an invariable and immediate cessation of men- struation when the ovaries have been re- moved. Or we may say with Schroeder, that menstruation without ovaries is due to habit, which, as Jackson well comments, is merely to reiterate without explaining. Schroeder naively says that this pseudo-ex- planation is better than to draw a conclu- sion directly opposed to our views upon the subject. Or we may admit with Lay cock,2 himself a believer in the ovular theory of menstruation, who said forty years in speaking of the periodicity of evolution : “We shall find that this periodic movement is not limited to the ovaria, but that it is an affection of the general system in which the ovaria partake.” We have no logical es- cape from the conclusion that the genital organs were not made for menstruation, but menstruation for the genitals, and that the primary impulse is to be sought in either the blood or the nervous system. The older writers believed that there was a periodical plethora of the blood which modern research does not corroborate. Furthermore, in the case of the Hungarian sisters, the blood vessels were united at the loins, giving them a common circulation, and yet their menstrual period differed. 3 The nervous system still remains, and with this general statement we may for the pres- ent remain content. Whether the gangli- onic, vaso-motor or spinal nerves are the presiding agency is hardly settled yet with certainty, but it appears most probable that the pelvic nerve-center in the lumbo-sacral cord controls this and all sexual phenome- na. The respiratory center of the fetus is quiescent. But when the proper conditions of its action are present, i. e., when the child is born, it straightway acts rythmically upon the proper muscles. So during child- hood the menstrual center is quiescent; but when the ovaries are developed it likewise begins to act rythmically throughout the woman’s sexual life. These views may be thus formulated : 1. Menstruation is a periodical systemic act, in which there is a general increase in vascular tension and a special determination of blood to the pelvic viscera. It has for its object the increasing of the blood supply of the ovaries in order to ripen Graafian vesicles, and the renovation of the uterine mucous membrane. 2. If the ovaries are removed, the coin- cident ablation of the peripheral nerve fila- ments supplying them exerts a trophic or reflex action upon the controlling nerve center, and in many cases causes a cessation of the menstrual impulse, but in some cases does not. 3. If the capillaries of the uterine mu- cous membrane resist the vascular tension of the menstrual period and fail to rupture, capillaries in other parts of the body may succumb to the strain and a vicarious dis- charge of blood takes place. When the vi- carious hemorrhage is coincident with a uterine flow, we may assume as probable one or more of these conditions. The vas- cular tension may be unusually great. The capillaries from which issue the supple- mented discharge may be unusually weak. The uterine flow may be due to an ob- structed condition of its circulation, from pressure upon its veins due to displacement, hyperplasia or tumors and not entirely to the usual and normal causes. This point is still in need of closer inves- tigation, but we may congratulate ourselves that after centuries of study and numberless theories, we are at last approaching a firmly settled knowledge of the real nature of men- struation and of its many and interesting complications. 1. Midwife, ist edition, page 96. 2. Op. cit., page 43. 3. American Journal Ostetrics, 1876.