NOTE ONpTHE TREATMENT OF AMENORRHCEA WITH PER- MANGANATE OF POTASH. -BY- Thomas A. Ashby, M.D., OF BALTIMORE. Read before the Baltimore Gynascological and Obstet- rical Society, May 10,1887. (Jleprint from the Maryland Medical Journal of June ith, 1887.) BALTIMORE: Journal Publishing Co., Prints 209 Park Avenue, NOTE ON THE TREATMENT OF AMENORRHCEA WITH PER- MANGANATE OF POTASH. THOMAS A. ASHBY, M.D., OF BALTIMORE. Since attention was first called to the therapeutic value of permanganate of potash in ainenorrlioea and other men- strual disturbances by Drs. Ringer and Merrell, I have had occasion to employ this drug in a number ot cases of amen- orrlicea with results so satisfactory that I have come to regard it as one of the most to reliable emmenagogues we possess in a definite class ot cases. My own experience has been so accu- rately foreshadowed by Dr. Fordyce Barker and other observers who have written on this subject that I shall not attempt its lengthy discussion. My simple purpose is to confirm the facts so carefully observed by others with a re- port of a few cases, selected from a number of cases similarly treated, as ex- amples of the conditions in which the 2 permanganate of potasli is of most posi- tive value. In the treatment of amenorrhoea by drugs the well-known types of the con- ditions which may account for the ab- sence or scantiness of the periodic flow must be recognized. There are no drugs known to science which will establish a monthly flow when the organs so neces- sary to menstruation are totally absent or so feebly developed as to possess no power ot functioning. Emmenagogues certainly can prove of no value under such circumstances and it will simply be a wild waste of time to place any confi- dence in their employment. The most important preliminary duty in the treat- ment of amenorrhoea is to determine the underlying cause. We must first re- gard amenorrhoea as a mere symptom of a functional disturbance of the generative apparatus and with this'key attempt to un- lock the door which conceals from view the causative influences at work in the pro- duction of the symptoms under discussion. In many cases a physical examination of the pelvic organs will be required to ac- count for the total absence or scantiness of the periodic flow. It seems to me that this method should be employed in every case where the administration ot 3 drugs is proposed, except in the cases of young girls in whom the function is probably retarded by slow development or dependent upon conditions of anaemia or chlorosis. In this latter class of pa- tients the preliminary employment of iron or manganese is admissible until we have fully tried their effects with negative results. Physical examination is then the only rational method of de- termining the essential cause of the re- tarded or feeble menstrual function. It is not my purpose to discuss the treatment of the various forms of amen- orrhoea, but to confine my remarks strictly to the indications calling for the employment of permanganate of potash in this condition. I can possibly make my thoughts clearer by the relation of cases which illustrate the points I wish to present. I have selected three cases which pre- sent three different types of amenor- rhcea. Each case offers an explanation of a functional disturbance depend- ent upon entirely different causes in which the permanganate of potash acted most satisfactorily in correcting the underlying trouble and in establish- ing a normal periodic flow. Case I.—Miss A. B., single, aged 28 4 years, has suffered for eight years past with uterine disease. At the beginning of her menstrual life she experienced a scanty How, accompanied with dysmen- orrhcea. She was treated by a distin- guished gynaecologist in a distant city for this condition, both'locally and con- stitutionally. Atone time the operation of posterior section was proposed by her medical attendant,but was refused by her- self and friends. Her health gradually im- proved under a change of location, diet and habits ot living. For several years she was under no special treatment, but during all this time her menses were scanty, irregular and invariably accom- panied with pain. During menstruation she was almost invariably confined to her bed, suffering with pains and cramps in the pelvis and lower limbs,with violent flushes of blood to her head, associated with headache and facial neuralgia. During this time nausea and vomiting were invariably present and her appetite was totally gone. The menstrual flow lasted from three to six days. The amount of blood lost was about one-third the normal flow. After the subsidence of menstruation her general health during the inter-regnum was only fairly good. She was plump, ruddy 5 and well-nourished, but complained con- stantly of weakness, general languor and dizziness. Her appetite was seldom vigorous; her secretions were seldom perfectly regular and normal. Whilst not positively sick, except during men- struation, she wa§ seldom positively well. She is a young lady of uncom- mon grace of manner and intellect, small in statue, but pretty in form and features. Her intellectual accomplish- ments are far above the average. As pre- viously stated she had several years prior to the date of my own observations been treated locally for uterine disease. This treatment had brought great prejudice in her mind against this method. She pre- ferred to suffer, as she expressed it, rather than undergo any further treat- ment by local examination. Drugs of various kinds had been employed with almost negative results. About this time my attention was called to the value of permanganate of potash by the well known communication of Drs. Ringer and Merrell. I at once proposed this drug. In fact I secured for her the two grain gelatine coated pills and gave them to her. She began taking one thrice daily and continued their use for some weeks. The result was so satisfac- 6 tory that she has continued them from time to time as the occasion requires with more decided benefit than ever be- fore obtained from any form of medica- tion used. The periodic flow became more profuse, the pain less severe and those symptoms referable to a distur- bance of this function have in great measure disappeared. I think I am warranted in stating that the drug has been of great service and has accom- plished for her what had not been ob- tained from any other emmenagogue. Case II.—Mrs. R,., aged 26, married sixyears, sterile, has always enjoyed good health, but has never menstruated lon- ger than one or two days and has had a very scanty flow. Menses come on regular each month, but during the time she suffers with flushes of blood to head and face and with giddiness. She is extremely anxious to bear children and with this object in view came under treatment for the relief of her sterility. Physical examination revealed a small nterus, slightly anteilexed and somewhat depressed in the pelvis. The vaginal cervix is small and conical. The canal readily admits the sound to the depth of one and three-fourth inches. There is some slight catarrh of cervix but not 7 enough to account for sterility. The ovaries could not be accurately made out by examination. The only explanation I could find for the condition of scanty menstrual flow and associated sterility was the unusually small but well-formed uterus. I prescribed permanganate of potash in one grain doses, gelatine coated pills, administered thrice daily. These were taken as ordered. The menstrual flow came on two weeks later at the regular epoch without pain and more profusely and comfortably than the pa- tient had ever experienced. The flow lasted four days and the amount blood lost was estimated at three times the quantity of any previous period. The patient had been advised previously to notice all of these facts. She came to see me after the period had subsided, her face animated and feelings gleeful over the result. She was greatly encouraged by the result and I confess that I somewhat shared her feelings. She now continues to take' these one grain pills as follows : One pill once daily during the inter-men- strual period, except the week antedating the flow during which time and during the time of flow she takes one grain thrice daily. The result has so far been eminently satisfactory. It is too soon to say whether the establishment of a regu- lar monthly flow will have any effect upon her sterile condition. This problem time must solve. I simply relate this case to show the value of the per- manganate of potash as an emrnena- gogue. Case III.—Miss W., aged 19, single, not well developed mentally or physi- cally for her age, has never menstruated properly. The flow is irregular, scanty, painful and pale in color. She also suffers with constipation and general sluggishness of her portal circulation. This patient had been examined per vaginam before she came under my ob- servation and the operation ot divulsion had been advised for the relief of stenosis ot the cervix. I found the uterus small, anteflexed, and somewhat prolapsed. The vaginal cervix was small and coni- cal, but the cervical canal was patulous enough to allow the scanty blood thrown off during menstruation to escape. I did not think the operation of divulsion advisable until other methods of relief had been tried. I advised the use of hot water vaginal enemata twice daily, and suggested that the habits and occu- pation of the patient be varied. I also prescribed permanganate of potash in 8 9 one grain doses gelatine coated pills thrice daily. These were taken as or- dered. The next menstrual flow came on more profusely and satisfactorily than previous flows had been. At the end of the period she was instructed to dimin- ish the dose to one grain once a day, and again to repeat the three doses the week preceding and during the flow. She has informed me that this method has given her much relief, that the flow is freer and brighter in color, accompanied with less pain and less bodily distress generally. It is too soon as yet to draw positive conclusions from the data furnished by this case but I think I can fiankly accord to the drug a positively good effect and that I am warranted in saying that it is a utferine stimulus of no uncommon value. When a drug accomplishes results which were not obtainable by other agents employed it is fair to accord to it similar virtures when again employed under similar con- ditions. The only way we can prove the positive value of an agent is from" the combined testimony of a number of different observations made by different observers. If we frankly present our data and summarize our conclusions the historian who sifts the wheat from the 10 tears will be able to record a just esti- mate of the facts collected. It is with this object in view that I offer these brief notes which I have illustrated with cases here briefly presented. There can be little doubt now, I think, that manganese is a uterine tonic of decided merit. Whilst it has been classed among those agents which act as “Indirect Eminenagogues” my own ex- perience inclines me to the opinion that its acts upon the menstrual function in other directions than as a corrective of anaemia and chlorosis. It seems to have the power of provoking a determination of the blood to the pelvic organs and of so modifying the vascular supply of the uterus as to enable this organ to relieve itself of blood by the necessary process of functional depletion. Its action is more nearly allied to that of ergot, savine and quinine in having a direct stimulating effect upon the uterus, though lacking the ecbolic action of these agents. It is true also that man- ganese acts as a general corrective of anaemia producing like iron a general improvement in the quality of the blood. As compared with iron, however, its value in anaemia and chlorosis is in- significant. It is probable the drug acts 11 in two ways, first as a general tonic and second as a direct emmenagogue. If this view of its action be the correct one its administration is indicated in those cases of amenorrhoea dependent upon a debilitated condition of the sys- tem with which we find associated an atonic and arrested action of the men- strual function, a condition most fre- quently observed among young girls and sterile women who have been edu- cated under a forced system of mental training or whose habits, occupations and surroundings have been unfavorable to the complete development and suc- cessful evolution of the processes of ovulation and menstruation. Some valid objection has been made against the use of the permanganate of potash on the ground of its objection- able taste and unpleasant effect upon the stomach. The great affinity of the drug for oxygen leads to its rapid de- composition when brought in contact witli organic matter so that this fact must be constantly borne mind in its administration. I have invariably pre- scribed the gelatine coated pill and have as yet had no serious complaint from any of my patients of any unpleasant effects 12 following its use. 1 am therefore inclined to the opinion that when the drug is given in pill form gastric distubances may be prevented.