Reprinted from Annals of Gynaecology and P.-ediatry, March, 1894. 
Profuse Menstruation.1 
BY DR. CHARLES P. NOBLE, 
PHILADELPHIA. 
We shall consider in this paper that 
profuse menstruation is synonymous 
with menorrhagia, or too great loss of 
blood at the menstrual period. Our 
subject will then embrace all those 
conditions which can give rise to this 
symptom. The terms profuse men- 
struation and menorrhagia are of prac- 
tical value, and have come down to us 
from the older gynaecology, which was 
almost purely clinical, and dealt but 
little with the pathological conditions 
at the basis of symptoms. 
The causes of menorrhagia are nu- 
merous. They are best grouped as 
constitutional, general, and local. 
Among the constitutional causes we 
have the haemorrhagic diathesis and 
scurvy. Among the general causes 
cardiac and hepatic diseases are the 
most important. Whatever will bring 
about a lack of tone in the general 
circulation will predispose to pelvic 
congestion and menorrhagia. Incom- 
petency of the cardiac valves and cir- 
rhosis of the liver are the most fre- 
quent of the general causes of men- 
orrhagia. Chronic Bright’s disease 
is also a cause of menorrhagia; but 
in such cases it is questionable whether 
it is the kidney-disease itself or the 
associated morbid condition of the 
blood-vessels and of the heart, which 
is the real cause of the profuse men- 
struation. 
The local causes of menorrhagia 
are: 
Pelvic congestion. 
Endometritis. 
Metritis. 
Adenoma. 
Polypus. 
Fibroid tumors. 
Carcinoma or sarcoma. 
Retained products of conception. 
Haematocele. 
Certain diseases of the uterine ap- 
pendages, especially cystic degenera- 
tion of the ovaries. 
A glance at this long list of causes 
of menorrhagia makes it apparent 
that it will be impossible in a brief 
paper to more than glance at the 
nature of these conditions, and to 
summarize our knowledge of their 
treatment. 
It is worthy of comment that the 
common causes of menorrhagia vary 
with the period of life to which the 
patients belong. In young virgins, 
shortly after the onset of puberty, 
menorrhagia at times occurs. Under 
these circumstances it is due to the 
fact that the menstrual function has 
not been perfectly established. There 
is lack of control on the part of the 
nervous system, both of the menstrual 
function itself and of the vaso-motor 
nerves in general. In the cases which 
have come under my observation this 
has appeared to be the cause of the 
profuse menstruation. These girls 
were plainly “ growing too rapidly,” 
they were “shooting up,” and had the 
lax tissues characteristic of such indi- 
viduals. 
1 Read before the Medical Society of the State of 
New York, February 7, 1894. 2 
CHARLES P. NOBLE. 
Menorrhagia in young childbearing 
women is usually due to some mishap 
in connection with pregnancy and 
parturition. An incomplete abortion, 
a subinvoluted uterus, laceration of 
the cervix, and retroversion of the 
uterus are the most frequent causes 
of menorrhagia in women of this class. 
Inflammatory disease of the uterine 
appendages is also frequently present 
in women at this period of their lives, 
and menorrhagia due to this cause, 
with coincident endometritis, is quite 
common. 
Menorrhagia occurring in women 
approaching the forties, and in those 
who are older, is of suspicious 
import. In younger women, as a rule, 
it is a symptom of some curable con- 
dition, and is of importance only be- 
cause of its severity,—the loss of blood 
producing anemia, and breaking down 
the patient’s health. In older women 
it has a very different signification. 
It is almost always due to gross dis- 
ease of the uterus. These women, as 
a class, have passed the period of 
childbearing, and their sexual organs 
are being prepared for the retrograde 
changes Which take place at the men- 
opause. / As we know, it is a law 
that tissues, especially glandular tis- 
sues, which are undergoing atrophic 
changes, are most apt to develop ma- 
lignant growths. The uterus is no 
exception to this rule, and cancer is 
extremely common among the class 
of women under consideration. 
The ancient tradition that it is nat- 
ural and proper for a woman to bleed 
profusely and irregularly when she 
approaches the period of the meno- 
pause, is the indirect cause of many 
preventable deaths from cancer of the 
uterus. This traditional belief is 
generally accepted by women them- 
selves, and, unfortunately, is advo- 
cated by many physicians who have 
not given the subject of diseases of 
women much study. This teaching 
they received as students, and although 
it has long been shown to be false they 
have never abandoned it. It is nat- 
ural that women should hold to this 
opinion, because it was quite current 
in the profession a generation or two 
ago. Popular beliefs are usually a fair 
reflex of what was the professional 
teaching of fifty or seventy-five years 
before. Believing it to be natural at 
their time of life, women disregard a 
menorrhagia when they are forty or 
fifty, which would cause them much 
uneasiness if they were twenty-five or 
thirty. The. same is true of a leucor- 
rhoea. In this way, but too often, car- 
cinoma is permitted to develop to the 
stage of ulceration, and to that of sec- 
ondary deposit, before the surgeon is 
consulted. Perhaps a physician is 
consulted at an earlier period who is 
a believer in the doctrine of climac- 
teric haemorrhages, and who soothes 
the patient with the assurance that 
there is no occasion for alarm, as “ it 
will all come right at the change of 
life and so the poor victim rests in 
fancied security until she has a rude 
awakening a little later, and discovers 
that death is inevitable owing to the 
inroads which the disease has already 
made. My own experience is so dis- 
tressing with reference to the man- 
agement of cases of cancer that I 
feel very strongly upon this subject. 
About one-tenth of all the cases which 
come under my observation are the 
victims of cancer, and of these not 
more than one in ten have consulted 
me sufficiently early to enable me to 
offer any reasonable ground of hope 
of being able to affect a cure by a 
radical operation. 
While it is true that cancer is a PROFUSE MENSTRUATION. 
3 
very common, if not the most usual, 
cause of menorrhagia in women ap- 
proaching the menopause, it is by no 
means the only one. Endometritis, 
adenoma, and fibroid tumors are also 
frequent causes at this period of life. 
It is a striking fact that whereas, in 
young virgins, the causes of menor- 
rhagia usually have to do with the 
nervous system, and that in young 
childbearing women menorrhagia is 
usually due to some mishap connected 
with pregnancy, that in older women 
it is almost always due to gross dis- 
ease of the uterus. 
Treatment.—As loss of tone of the 
vascular system predisposes to menor- 
rhagia, it follows that by building up 
the general health and improving the 
tone of the circulation much can be 
accomplished in any case of menor- 
rhagia. Digitalis, strychnine, and 
ergot act directly upon the muscular 
structure of the heart and arteries, 
and lessen pelvic congestion, and can 
sometimes be depended upon to les- 
sen hemorrhage from the uterus, pro- 
vided the local morbid conditions are 
not of a very marked character. 
The local treatment of menor- 
rhagia depends, of course, upon the 
nature of its cause, so that the most 
important point is first to make a 
diagnosis. One of the drawbacks to 
the older nomenclature, to which our 
present title belongs, is that it does 
not tend to favor accurate diagnosis. 
There is no treatment for menor- 
rhagia per se, and that fact should 
be distinctly emphasized. Many a 
woman has gone to her death from 
unrecognized cancer or cancer recog- 
nized too late for its eradication by 
operation, because the attending 
physician was satisfied with the diag- 
nosis of menorrhagia, and addressed 
his treatment to that entity. Every 
case of menorrhagia deserves careful 
study, and this is especially true when 
it occurs in women who are upward 
of thirty years of age. A careful 
inquiry into the case will usually put 
the astute physician upon the right 
track. In a case of short duration, 
in which the amount of blood lost is 
inconsiderable, especially if there be 
no complaint of pelvic pain and no 
breaking down of the general health, 
it may be permissible to treat it upon 
general principles,—that is, to regu- 
late the bowels, the habits of the in- 
dividual, to treat any symptoms which 
may be present, to prescribe regular 
habits of living, and to administer 
digitalis, strychnine, and ergot. Es- 
pecially is this the case if the patient 
be unmarried, and if the discharges 
are free from offensive odor. The 
physician would be the more inclined 
to make use of general treatment 
only if in such a case the heart was 
found to be incompetent or the liver 
congested. But he should not permit 
himself to continue the treatment 
without an accurate diagnosis unless 
the patient promptly and steadily 
improves. 
Accurate diagnosis is the key-note 
to success in the management of 
cases in which menorrhagia is a symp- 
tom. That this is a truism makes it 
none the less important that it be 
followed out faithfully in the manage- 
ment of each individual case. With 
the exceptions already referred to, 
and young girls, it should be the 
maxim of the practitioner that every 
woman having menorrhagia should 
have a careful pelvic examination. 
A careful examination should be 
made to determine whether or not 
pelvic congestion is present ; the size, 4 
CHARLES P. NOBLE. 
shape, consistency, and position of 
the uterus; whether or not it be in- 
flamed ; whether it contains a tumor 
or the products of conception. Also 
the condition of the uterine ap- 
pendages should be investigated. 
Whether or not these are healthy, 
and if not, the morbid condition 
present; whether this be a tumor, 
inflammatory trouble, or a haemato- 
cele. The condition of the general 
circulation, the heart and the liver 
should also be investigated, and in no 
case should an examination be con- 
sidered complete until all of these 
conditions have been considered. 
It may prove of interest if I give 
succinctly my own views concerning 
the management of the various con- 
ditions which give rise to menor- 
rhagia. 
Pelvic congestion, when not due to 
or accompanied by structural disease 
in the pelvis and when not the result 
of a recent parturition, is best treated 
by remedies addressed to the general 
health,—by tonics, by heart-stimu- 
lants, and by proper hygienic meas- 
ures, including active out-of-door ex- 
ercise. Pelvic congestion alone is 
seldom the cause of menorrhagia, ex- 
cept after parturition, but it predis- 
poses to endometritis, and in this way 
indirectly becomes a cause. 
Endometritis and metritis, when not 
complicated by inflammatory disease 
of the uterine appendages, are treated 
most satisfactorily by dilatation of the 
cervix and a careful and thorough use 
of the sharp uterine curette and cut- 
ting curette forceps. In this way 
more can be done in ten minutes than 
can be done in ten weeks in any other 
way. In my hands, in the class of 
cases referred to, the results obtained 
have been very satisfactory, and the 
failures to cure and the recurrences 
have been exceptional. While stating 
this in general terms, it is admitted, 
of course, that the final stages of 
areolar hyperplasia are not specially 
influenced by the use of the curette, 
or by any other form of treatment 
except the ablation of the uterus. 
Adenoma is likewise best treated 
by the use of the sharp curette. 
Malignant adenoma calls for pan- 
hysterectomy. 
Polypi should be removed per va- 
ginam, and the endometrium thor- 
oughly curetted. 
Fibroid tumors, which are giving 
rise to menorrhagia, should be re- 
moved per vaginam when they belong 
to the submucous variety and can be 
removed from below, otherwise they 
should be removed by hysterectomy. 
Carcinoma and sarcomaoi the uterus 
call for pan-hysterectomy whenever 
the disease remains localized in the 
uterus ; otherwise a partial operation, 
having for its object the removal of 
necrotic tissue, or the prevention of 
haemorrhage or foul-smelling dis- 
charge, may or may not be advisable 
in individual cases. When the dis- 
ease has involved the pelvic glands to 
any considerable extent, and when 
pain has become a marked feature in 
the case, I have seldom found much 
benefit from operation. It may pre- 
vent or control the foul-smelling dis- 
charges, but it seldom modifies the 
pain, unless this has been of an in- 
flammatory character due to septic 
absorption from the necrotic surface 
of the cancer. Every case, however, 
should be judged upon its merits, 
and, as the result in all cases which 
are far advanced is an inevitable and 
more or less painful and disgusting 
death, it can at least be said that PROFUSE MENSTRUATION. 
5 
operation can hardly make matters 
worse, even though it fails to afford 
much relief. 
The treatment of retained products 
of conception is their removal. 
Hcematocele is due almost always to 
a ruptured extra-uterine pregnancy, 
and should be treated by coeliotomy, 
removal of the pregnant tube and of 
the effused blood. 
When endometritis and menorrha- 
gia are produced by inflammatory 
disease in the uterine appendages, or 
by ovarian tumors, the conditions are 
such, as a rule, to call for coeliotomy 
and the removal of the diseased ap- 
pendage or appendages. 
Cystic degeneration of the ovaries is 
at times a cause of menorrhagia and 
metrorrhagia. A number of such 
cases have come under my care. In 
these cases the ovaries were not 
markedly enlarged, and upon bi- 
manual examination, it was only pos- 
sible to say that the ovaries were 
rather large and tender. In these 
cases curettement, the rest cure, and 
all manner of internal medication was 
tried without avail, as the haemor- 
rhages recurred very soon, and the 
patients were not cured until the 
ovaries were removed. In each of the 
cases cure promptly resulted. 
I have as yet said nothing about 
the use of electricity in the treatment 
of menorrhagia. The advocates of 
electricity claim that this is perhaps 
the field in which it is of the greatest 
value, and I am inclined to believe 
that, for simple cases of endometritis 
or metritis, it is capable of effecting 
a cure. But the method of treatment 
is tedious and painful, and, when suf- 
ficiently strong currents are employed 
to assure the effect upon the uterus, 
the method is not without danger. 
As compared with the curette, I be- 
lieve it is more dangerous, less cer- 
tain, more painful, and much less 
satisfactory. 
My own experience with the use of 
drugs in the treatment of menorrhagia 
has not been large. Digitalis, strych- 
nine, and ergot have proved them- 
selves in my hands to be of real 
value, and, except in those cases in 
which the local conditions have been 
so bad as to make it irrational to ex- 
pect much effect from constitutional 
remedies, the results from the use of 
these agents have been satisfactory. 
My experience with other drugs has 
been small. Hydrastis canadensis 
has been used to some extent, and I 
have never been able to satisfy myself 
that it has the slightest action in the 
way of controlling uterine haemor- 
rhages. 
There are two other forms of treat- 
ment of value, especially in bridging 
over an emergency in the treatment 
of cases of menorrhagia. These 
methods are systematic rest in bed 
and the use of the vaginal tampon. 
With the exception of those cases in 
which menorrhagia is due to malig- 
nant disease, to adenoma, or to the 
retention of the products of concep- 
tion, rest in bed has a very positive 
influence in lessening the amount of 
blood lost. It is of practical value 
chiefly in the management of cases 
which are seen late, after so much 
blood has been lost that the patients 
are suffering from acute anaemia and 
profound prostration, so much so that 
it might not be safe to anaesthetize 
them in order to institute any radical 
method of treatment. This reference 
applies especially to cases of fibroid 
tumor. I have again and again in 
such cases, when consulted under the 6 
CHARLES P. NOBLE. 
circumstances referred to, been able to 
greatly improve the condition of the 
patients by putting them to bed, keep- 
ing their bowels regular, and perhaps 
administering strychnine, digitalis, 
and ergotine. I have in this way been 
enabled a number of times to do hys- 
terectomy with success, when I am 
satisfied, had the operation been per- 
formed when the patient first came 
under observation, the result would 
have been fatal. 
In certain cases the use of the va- 
ginal tampon is of great service in 
temporarily arresting haemorrhage. 
In the class of cases just referred to, 
when the bleeding is aggravated by 
the onset of the menstrual period, by 
firmly tamponing the vagina during 
the days when haemorrhage otherwise 
would be most free, it is quite possi- 
ble to limit the loss of blood to a very 
small quantity. This has been advo- 
cated as a systematic means of man- 
aging certain otherwise intractable 
cases of menorrhagia, and I can add 
my testimony to its value, at least as 
a temporary expedient in the manage- 
ment of certain cases of uterine 
haemorrhage. 
The ligation of the uterine arteries 
offers another means of controlling 
haemorrhage from the uterus, no mat- 
ter what the immediate cause of the 
haemorrhage may be. As a prelimi- 
nary operation, in dealing with a small 
class of fibroid tumors, in which a 
large amount of blood has been lost, 
and in which acute anaemia is present, 
this operation offers much. Likewise 
in certain cases of persistent haemor- 
rhage after the removal of the uterine 
appendages, in combination with thor- 
ough curettement of the uterus, I 
believe that this procedure will be of 
great value. 
Certain cases of persistent and re- 
current haemorrhage have come under 
my observation, which have resisted 
all the usual methods of treatment. 
In such cases the cause is usually ma- 
lignant adenoma. When the micro- 
scope clearly shows this to be the 
case, or when the trouble recurs time 
and again, after thorough curettement 
of the uterus, even though the micro, 
scope does not demonstrate the pres- 
ence of malignancy, hysterectomy is 
indicated. In such cases it is a life- 
saving measure to prevent death from 
haemorrhage. In cases in which the 
microscope does not show malignancy, 
it would be proper to make use of elec- 
tricity, after the failure of curettement, 
before resorting to hysterectomy. In 
one case in whichcurettement repeated 
three times failed to cure, and in which 
the removal of the somewhat diseased 
uterine appendages (cystic ovaries, 
catarrhal salpingitis) likewise failed 
to cure, this result was accomplished 
by packing the uterus with gauze 
squeezed out of 50 per cent, chloride 
of zinc solution, which brought away 
a slough of the endometrium, and a 
part of the underlying muscularis. 
This very radical and somewhat haz- 
ardous method of treatment I should 
recommend only in exceptional cases, 
and not in any case in which the ap- 
pendages have not been previously 
removed. 
I have as yet made no mention of 
the treatment of menorrhagia by the 
application of carbolic acid, iodine, 
perchloride of iron, nitric acid, or 
other caustics to the endometrium, 
either by means of a cotton-wrapped 
applicator or a uterine syringe. The 
reason for this omission is that I be- 
lieve these methods to be either in- 
efficient or dangerous or both. The PROFUSE MENSTRUATION. 
7 
milder escharotics are inefficient; the 
more powerful are dangerous in that 
their action cannot be controlled 
within conservative limits. The ex- 
perience of the generation preceding 
us has so well demonstrated the dan- 
gers attendant upon this form of 
treatment that it is unnecessary for 
us to go over the same ground. 
Conclusions.—(1) Menorrhagia in 
young virgins is usually functional, 
due to disturbances in the vaso-motor 
nervous system, or to relaxation of 
the tissues ; in general caused by the 
rapid growth which at times takes 
place about the time of puberty. Be- 
cause of its pathology menorrhagia in 
young virgins is usually curable by 
general treatment. 
(2) Menorrhagia occurring in young 
childbearing women is usually due to 
some mishap in connection with preg- 
nancy or parturition, such as the re- 
tention of products of conception, 
laceration of the cervix or perineum, 
retro-displacement of the uterus, sub- 
involution, inflammation of the uterine 
appendages, and pelvic congestion. 
Menorrhagia in this class of women 
is curable. It usually requires local 
treatment of an operative nature. 
When due to subinvolution and mal- 
positions of the womb, operation is un- 
necessary. 
(3) Menorrhagia in women ap- 
proaching the forties and in those 
who are older is usually due to gross 
diseases of the uterus, such as fibroid 
tumors, polypi, adenoma, or malignant 
tumors. Menorrhagia occurring in 
this class of women, except when due 
to advanced malignant disease, is 
curable, but almost invariably requires 
operative treatment applicable to the 
disease present in the particular 
case. 
(4) As menorrhagia is a symptom 
and not a disease, an exact diagnosis 
is requisite in every case. With the 
exception of young virgins it is desir- 
able that a physical examination of 
the pelvic organs be promptly made. 
The importance of this examination 
is the greater with the increasing age 
of the patient. Special considerations 
should influence the practitioner to 
postpone the local examination in the 
unmarried unless it be reasonably cer- 
tain from the symptoms that gross 
local disease is present. 
(5) There is no treatment for men- 
orrhagia per se. By general measures, 
such as rest in bed and the use of 
digitalis, strychnine, and ergotine, 
pelvic congestion can be lessened, 
and in that way menorrhagia can be, 
at least in part, controlled; but it 
cannot be too strongly insisted upon 
that in every case of menorrhagia an 
exact diagnosis must be made and the 
appropriate treatment addressed to 
the disease which is present.