[Reprinted from the New York Journal of Gyn/ecology and Obstetrics 
for May, 1894. 
IRREGULAR MENSTRUATION* 
By E. W. Cushing, M. D., Boston, Mass. 
In considering the question of irregular menstruation I find my- 
self somewhat embarrassed by the limitation of my part of the whole 
question, for I must avoid treating of profuse menstruation on the 
one hand and of scanty menstruation on the other, while, to be 
strictly accurate, what is really menstruation is not irregular, and 
what is quite irregular is not menstruation. I find myself, therefore, 
occupying as it were a geometrical point, which has position but 
neither length, breadth nor thickness ; if therefore I am to consider 
the subject at all, I must trench on the province of all the other 
speakers in spite of the adjurations of Dr. Currier. 
In the first place we have to consider the irregularities which 
attend the establishment of the menstrual function at puberty. 
These are sometimes so severe as to demand active treatment owing 
to the profuseness of the haemorrhages, but more often we are called 
to give advice concerning scanty, delayed or omitted menstruation. 
A certain amount of irregularity at this period of life as well as at 
the menopause is so common that it may almost be considered as 
regular, and it is only special cases which under the care of the 
physicians. 
Where menstruation is precocious or excessive it is well to con- 
sider whether the girl is leading a life as quiet and as free from ex- 
citement as should be the rule at such a time, while on the other 
hand when the discharge occurs only occasionally and at irregular 
intervals care should be taken to avoid undue confinement in school 
and overstudy and to enjoin such an amount of good food and exer- 
cise in open air as a young girl ought to have. 
* Read-before the New York State Medical Society, as part of an assigned dis- 
cussion on the subject: "Menstruation and Its Abnormalities." February 6, 1894. 2 
E. W. Cushing, M. D. 
It is obviously impossible within the limits of this paper to say 
anything more in regard to the treatment of the irregularities of men- 
struation for, as stated above, the only treatment required is for pro- 
fuseness or scantiness, for continuous duration or total absence of the 
flow, and all these questions are to be considered by other speakers ; 
the only point left for me to consider appears to be the differential 
diagnosis between irregularities of menstruation and various other 
bloody discharges from the vagina which are usually supposed to be 
of a menstrual nature by the patients, so that for this reason the early 
stages of very serious maladies are often overlooked. First in fre- 
quency and in importance come the sudden and violent haemorrhages 
at or about the menstrual epoch, or the total suppression of menstrua- 
tion, due to inflammation of the uterine appendages and of the fundus 
of the uterus : these attacks are usually attributed by the 
" catching cold "-and sometimes this appears to be the case-or, 
perhaps we should say more properly, the occasion which allows 
various infecting organisms to excite inflammation of the uterine and 
tubal endometrium. It is unnecessary here to describe further the 
long train of troubles which may follow such an attack of pelvic in- 
flammation, troubles which are liable to be associated at all stages 
with irregular or painful menstruation. 
Next in order we may consider the irregularities of menstruation 
associated with subinvolution of the fundus, running on into fungous 
endometritis : usually in these cases all sorts of medicines have been 
without effect until some one makes a diagnosis and adopts the proper 
treatment-as a rule, of a surgical nature. 
One of the most important affections, of which irregular menstrua- 
tion is a symptom, is extra-uterine pregnancy. This condition is cer- 
tainly very much more common than was heretofore supposed, as is 
shown by the large number of operations which are now performed to 
relieve it. Probably in a large proportion of cases haematocele should 
also be considered as due to extra-uterine pregnancy. Now, in al- 
most all cases of this affection the first symptom observed is irregu- 
larity of the menstruation. It sometimes ceases entirely as in ordinary 
pregnancy, but more often it is diminished or is missed once and re- 
turns afterward, but not just at the regular time, or there is more or 
less continuous escape of blood often accompanied by discharge of 
decidual membrane and complicated by pain ; so the patient does not 
know whether she is really pregnant or not. Of course, in all such 
cases, the diagnosis is of the utmost importance and that being made, 
the proper treatment can be at once adopted. Irregular Menstruation. 
3 
During the middle period of a woman's life, especially if she is 
married and the mother of a numerous family, the rapid succession of 
pregnancies, with the various accidents and sequelae of parturition, 
together with the care and labor of the household and the conditions 
and relations incident to married life, make a certain amount of men- 
strual irregularity so common that the women hardly notice or trouble 
themselves about it; and when there is sufficient loss of blood or pain 
to lead them to consult a physician, the diagnosis is the main ques- 
tion ; it certainly is the duty of the physician to find out what is the 
real nature of the affection, instead of simply prescribing ergot or 
hydrastis or some other customary remedy. 
At any rate, if such medicines do not act promptly, and if inflam- 
matory disease or the condition or results of pregnancy have been ex- 
cluded, there is grave reason to suspect organic disease of some kind, 
such as fibroid tumor or cancer. 
Although neither of these diseases is strictly limited as to the 
period of life in which it appears, yet we see myoma more often in 
women under fifty, cancer of the cervix in women from forty to sixty- 
five and malignant adenoma, which degenerates into cancer of the 
body of the uterus, seldom under fifty. 
It would seem self-evident that the way to find out whether a 
woman has a myoma or a cancer is to examine her carefully and 
thoroughly, and yet I am pained to say that in many cases a great 
deal of time is lost, either owing to the refusal of the woman to sub- 
mit to examination or to the neglect of the physician to insist on 
making it. Here, again, a certain blind faith in the power of medi- 
cine, an easy routine or a want of appreciation of the importance of 
the subject very often leads to the loss of much valuable time. 
The diagnosis of myoma is not always easy. It is most apt to be 
confounded with hard inflammatory masses, with malignant disease of 
the fundus uteri or with ovarian growths, especially adherent dermoids 
which displace the uterus. This is not the place to go further into 
the question of diagnosis, still less of treatment. As soon as the diag- 
nosis is made, the supposed menstrual irregularity becomes the symp- 
tom of a definite disease and can be treated accordingly. 
If the failure to make an early diagnosis of a myoma is annoying, 
the failure to discover a cancer in its early stages is a disaster-a 
neglect which is well-nigh criminal. 
And yet, how many lives are trifled away for want of a diag- 
nosis ! How many women are dosed for months for irregular men- 
struation without examination. How many are treated for " ulcera- 4 
E. IV. Cushing, M. D. 
tions " for weeks until the disease has spread so, that it has gone into 
the lymphatics beyond the possibility of entire removal. How many 
women, instead of consulting their physician, run about among their 
female friends and are assured that it is only the change of life, 
which causes their irregular haemorrhages. Nevertheless, there is 
seldom any real difficulty in diagnosis of cancer of the cervix. If 
there is an old laceration, with ectropium and glandular growth of 
the cervical lips the appearances may resemble carcinoma and, on 
the other hand, the latter disease may for a time resemble or be en- 
grafted on the former. Yet it is easy to scoop or cut off a piece 
large enough for microscopic examination, and in fact it may be 
accepted as a rule with few exceptions that where a piece of the 
cervical tissue can be scraped or broken off with the finger-nail the 
disease is to be regarded as malignant and measures are to be taken 
at once in accordance with the nature and gravity of the affection. 
Somewhat more difficult of eaily diagnosis is malignant adenoma 
of the uterine body, which usually first makes itself known by uterine 
haemorrhages, not profuse but persistent. As this affection generally 
commences after the menopause, it would hardly be a subject for 
consideration here were it not for the fact that the women are prone 
to regard the bloody discharges as a recurrence or renewal of men- 
struation ; and they are often, in fact, rather proud of the prolonga- 
tion of their -uterine functions. The diagnosis is made by the micro- 
scope after curetting ; the cure is hysterectomy. It must, moreover, 
never be forgotten in studying the causes of irregular menstruation 
that they may lie far from the uterus or its appendages. Thus, 
menorrhagia may depend on disease of the heart, on violence of the 
emotions, on sexual excitement, etc. Amenorrhoea may depend on 
imperfect development, on incipient phthisis, on homesickness, 
change of climate, anaemia, sorrow, etc. 
It is impossible to do justice to such a subject in fifteen minutes 
and, if I may sum up all in a few words, I would say that in all cases 
of irregular menstruation we should search out the cause of the 
trouble, and if possible remove it. 
" Sublata causa tollitur effectus."