menstrual congestion, are also markedly affected. There is rectal
tenesmus, and on the part of the bladder frequent micturition and
dysuria. Remote organs are influenced either directly or by sympathy.
The breasts become tumefied and tender. There is flatulence, nausea, or
even vomiting. The nervous system, during normal menstruation in a
state of erethism, responds readily to the painful impressions, and
presents symptoms of the most varied character and degree, amounting
even to general convulsions.
Attacks of severe pain recurring at short intervals cannot but exert a
powerful deleterious influence upon the general health. Digestion is
interfered with, nutrition and sanguification are imperfectly
performed, and there is a continuous chain of deranged function. The
results to the nervous system, indirect and direct, and sometimes also
from the measures of relief resorted to, are most deplorable. From
every point of view this class of cases presents the strongest claims
for relief.
The discharge in dysmenorrhoea varies very widely in amount and
character. It may be so scanty as to border on amenorrhoea or so
profuse as to be menorrhagic. It may be more or less fluid than usual.
The expulsion of clots is a frequent feature, and the size and shape of
these sometimes give indications of value. Like other uterine
derangements, dysmenorrhoea is not a disease per se, but a symptom of
some pathological condition the exact nature of which is to be
ascertained whenever possible. Cases may be classified as follows: I.,
Obstructive or mechanical; II., congestive; III., neuralgic; IV.,
membranous. It cannot be too distinctly kept in view that this
classification, like many others, cannot be rigidly followed. The
dividing-lines are sometimes but faintly drawn by nature; some cases
present the features of more than one class; some by natural progress
pass from one class into another. Based upon leading clinical features,
this classification will assist in the study of the subject, facilitate
diagnosis, and aid in directing therapeutic measures.
Two classes given by some authorities are not included in the above
classification. They are spasmodic and ovarian dysmenorrhoea. If by the
former is implied painful contractions of the uterus during
menstruation, the cases fall into the first class given above, the
obstructive; and if irregular nervous action is implied, they belong to
the third, the neuralgic. The term ovarian has been applied to those
cases in which an abnormal condition of the ovaries exists, such as
inflammation, enlargement, or dislocation. Such conditions are not
easily ascertained during life; if ascertained, the fact throws light
on the etiology of the case; but for {194} treatment the case will
range itself, according to the clinical features it presents, among
those in which the vascular or the neurotic element predominates.
Obstructive or mechanical dysmenorrhoea is that form in which some
impediment exists to the free escape of the menstrual discharge. The
genital canal presents no exception to the general rule that when an
excretory channel is obstructed violent and painful expulsive efforts
are excited.
The causes which give rise to the obstruction are various. Among them
are the following: fibroid tumors of the uterus distorting, and polypi
obstructing, its cavity or neck; stenosis of the cervical canal, either
congenital or acquired, the latter often the result of the injudicious
use of strong caustics; a long and conical cervix; a contracted os,
sometimes so small as to be justly termed the pinhole os; versions and
flexions of the uterus.
The seat of obstruction is almost always uterine, but may be in the
vagina or at its entrance. There is much difference of opinion as to
the relative frequency of occurrence of obstruction at the internal or
external orifice of the cervix.
The pain in this form of dysmenorrhoea generally does not precede the
flow. In character it is sometimes like colic, but its leading feature
is expulsive effort. It occasionally so nearly resembles abortion as to
require care to distinguish between them. It is frequently
intermittent, presenting intervals of complete relief. In severity it
varies widely. In some cases the patient assumes and maintains a
certain position which she has learned affords her some relief. This
indicates with great probability uterine distortion from fibroid tumor.
The writer has met with a marked instance of this kind.
The flow is more irregular in this than in other forms. It is sometimes
extruded drop by drop; more often it appears in gushes, the fluid
accumulating and distending the uterus until expulsive efforts are
excited. Clots are often thrown off under these circumstances in shape
and size corresponding to the cavity of the uterus.
Absence of prodromata, presence of the fluid being necessary to excite
the pain, the intermittent and especially the expulsive character of
the pain, and the kind of clots, indicate the nature of the case. A
certain diagnosis, however, rests alone on physical examination. This
should be by the touch, bimanual and rectal, and the sound. Sometimes
additional aid will be derived from the speculum. By touch the form,
size, shape, and direction of the cervix are ascertained, and its
relations to the body of the uterus. The sound will give evidence as to
the patency and direction of the cervical canal and uterine cavity.
A diagnosis of obstructive dysmenorrhoea should not be rejected because
the patient occasionally passes a period without pain. In the male an
enlarged prostate may for a long time interfere but little with
micturition, and then all at once completely obstruct the flow of
urine. A diagnosis cannot be based alone upon the condition of the
cervical canal as found during the intermenstrual period. Two elements
are to be considered, each of which may, and doubtless often does, play
a part: tumefaction from the congestion attendant on the process, and
spasm. The latter, caused by reflex action excited by irritation in the
body of the uterus, assumes a leading position with those who claim
that obstruction is the {195} sole cause of dysmenorrhoea. That it
plays an active part in many cases cannot be doubted; that it is a
necessary condition of even spasmodic dysmenorrhoea is disproved by the
positive statement of Matthews Duncan, that in some cases he could pass
a sound freely into the uterus during the paroxysms.
A due estimate of the part which a uterine flexion plays in producing
the dysmenorrhoea is important, but very difficult. Theoretically, the
narrowing of the canal at the point of flexion should account for the
symptoms, but experience does not accord with theory. All cases of
flexion are not accompanied by dysmenorrhoea, and when so accompanied
removal of the deformity does not always cure. Siredey in 52
observations found only 22 cases of dysmenorrhoea. Emmet's
carefully-prepared tables show that in nearly 50 per cent. of
anteflexions menstruation is painless. The conditions necessary seem to
be extreme flexion, producing an acute angle. In less-pronounced cases
it is maintained by many that the flexion is an unimportant factor, and
that the dysmenorrhoea depends upon secondary conditions produced by
it, as endometritis and congestion. The problem is difficult, and each
individual case requires careful study. The facts indicate that there
is much in the pathology of this form of disease not yet fully
understood.
Congestive dysmenorrhoea depends upon an advance of the menstrual
congestion beyond the physiological limits. In these cases the patient
generally suffers for a few days before the period from a sense of
fulness, weight, and heat in the back and pelvic region. Pain follows,
is more or less severe, and varies somewhat in character, although
generally dull and heavy. The hypogastric region usually becomes
distended, and is sometimes very tender to the touch over the ovaries,
"especially on the left side, without any reason for the difference
being known." After a longer or shorter duration of these symptoms the
flow appears, and this is often, especially if free, followed by an
amelioration of the pain. In many cases, however, there is no remission
of the suffering upon the discharge occurring. Not infrequently the
general circulation is affected, the face is flushed, the skin hot, and
there is more or less fever.
The flow may vary widely as to quantity. It is often at first and for a
time more profuse than normal. Leucorrhoea frequently precedes and
follows it, persisting during the entire interval. During that time
also the patient suffers much from backache and bearing down, with
difficulty of walking or of remaining on her feet.
Upon examination the vagina is found hot and tumefied, and increased
arterial action is evident to the touch. The uterus is tender,
enlarged, and heavier than usual. In cases associated with or dependent
upon chronic inflammation or areolar hyperplasia the increase of size
of the uterus during menstruation is marked. The sound may be used to
determine the amount of enlargement and also the amount of tenderness.
In cases dependent on endometritis touching the interior of the organ
causes severe pain. Dyspareunia is frequently a symptom in this class
of cases.
The conditions upon which congestive dysmenorrhoea depends are various,
and may be either general or local or both combined. Plethora is rare
in females, and local congestions are much more frequently dependent
upon anæmia, the abnormal condition of the blood favoring them {196}
directly and also indirectly by its effect on the nervous system. In
past times gout and rheumatism were considered to act frequently as the
cause of dysmenorrhoea. They have almost disappeared from view since
the era of direct examination began. Malaria, however, as a possible
cause or a powerful factor should never be overlooked in regions where
it prevails. The sexual instinct plays an important rôle; enforced
abstinence, especially when suddenly brought about, and excess, being
alike effective etiological factors. Young widows and prostitutes are
both subject to this form of disease.
The local causes are numerous. Pelvic inflammations, as cellulitis or
pelvic peritonitis, give rise to the disease. Affections of the uterus
are frequent causes; displacements, as retroversion or prolapsus; and
inflammation, either parenchymatous or of the endometrium. Quite a
moderate grade of inflammation, as found during the interval, may,
under the increased congestion of menstruation, become extreme. Many
cases doubtless depend upon an ovarian influence even when no affection
of these organs can be made out. Scanzoni hazards the theory that the
maturation of Graäfian vesicles lying deeper than usual in the stroma
of the ovary is one cause of this form of dysmenorrhoea.
In neuralgic dysmenorrhoea the neurotic element preponderates. The
nerves play a part corresponding to that of the vessels in the
congestive form. In some cases of this class no organic lesions can be
discovered, and they are then termed idiopathic.
This form of dysmenorrhoea depends upon either a peculiar condition of
the general nervous system or upon hyperæsthesia of the sexual system,
or both combined. Either or both may have been inherited or acquired.
It is frequent in subjects of the hysterical temperament, and in those
presenting that preponderance of the nervous system so often seen as
the result of over-refinement, luxury, habits of idleness, and other
violations of hygienic law. Those subject to it often suffer from
severe headaches, neuralgia, and other nervous affections. It is often
caused by anæmia or chlorosis. Sexual influences, psychical or
physical, and especially those that excite without satisfying, are
sometimes efficient causes. Ovarian influence is often an important
factor; some authorities designate all those cases in which no
anatomical change can be found, ovarian. The prodromata of this form
are very apt to be some of those nervous attacks to which such patients
are liable, as headache or neuralgia, and they may be psychical, as
aberration of temper, undue irritability, or tendency to melancholy. In
character the pain is generally stated to be more acute than in the
other forms. It is subject to great and sudden alternations. In
acuteness and irregularity it often justifies the term spasmodic. From
these characters and from the absence of anatomical change a
differential diagnosis may be made. As in this form the most marked
nervous symptoms are witnessed, so are also the most pronounced
complications on the part of the general nervous system. They are often
hysterical in character, but may be of every kind and degree, even to
general convulsions, and mental aberration is sometimes a complication
or result.
Membranous dysmenorrhoea is characterized by the expulsion at the
menstrual periods of organized membrane, either as a whole or in
pieces. In the former case it is like a cast of the interior surface of
the {197} uterus. The expulsion of this membrane is accompanied by
pain, often of the most severe character. The pain presents well-marked
features; it is markedly expulsive, identical with that of the
obstructive form, closely resembling an abortion, to which the membrane
adds an additional element of similarity. This pain and these expulsive
efforts may continue twelve, eighteen, or twenty-four hours, and then
cease, to be renewed only at the next period.
This form of disease is rare--so rare that observers having a large
field of observation may never meet with over half a dozen cases. In
regard to many points very diverse views are held, and the limits of a
practical work do not permit even a statement of all of them. The
nature of the membrane is one of these points too important to pass
over. When thrown off entire, its internal surface is smooth and marked
by the openings of the utricular glands; its external or uterine face
is rough and villous. It presents the exact shape of the interior of
the uterus, with openings corresponding to the Fallopian tubes and the
os. It is impossible to escape the conviction that this membrane is the
lining membrane of the uterus, thrown off as a whole, instead of by
gradual melting down of its superficial layers, as in normal
menstruation. The microscope sustains this view, and this is the
generally received opinion; yet that the membrane is not always such is
testified by competent observers from observations with the same
instrument. It seems probable that this disputed point will be settled,
as have been so many others in medicine, in favor of both parties.
Siredey suggests the possibility of different kinds of membrane in
these cases, while Barnes boldly states this as a fact.
Various theories have been advanced to account for the formation of the
membrane. An abnormal course of conception, a changed ovarian
influence, a peculiar endometritis, have been from time to time
favorite terms in which to express our ignorance. Only in regard to the
first has unanimity been obtained. That the membrane is always a
product of conception is not now maintained by any respectable
authority. It is a well-established fact of the utmost importance that
such membranes may be expelled when there has never been sexual
intercourse.
The membrane of dysmenorrhoea is to be distinguished from fibrinous
masses, the remains of blood-clots from which the corpuscles have been
squeezed; from mucus coagulated into shreds by astringent injections;
and from the products of membranous vaginitis. Neither of these will
present much difficulty with the aid of the microscope. The case is
very different, however, when the membrane is to be distinguished from
the decidua of an early pregnancy. From a single specimen or a single
attack a diagnosis cannot be made. Thomas gives an instance of
disagreement as to the nature of the same membrane by two of the
highest microscopical authorities. The recurrence of the attacks at the
regular menstrual periods will establish the diagnosis.
The prognosis of dysmenorrhoea varies in the different classes. In the
obstructive form it will depend upon the curability of the lesion upon
which it depends, and the same may be said of the congestive. The
neuralgic cases do not yield readily to treatment, especially when
dependent upon a peculiar and perhaps inherited nervous constitution.
Caution should be exercised, however, in expressing an unfavorable
prognosis. {198} Like all nervous diseases in the female, it is subject
to great mutations without apparent adequate cause, and will sometimes
suddenly disappear in an inexplicable manner.
The membranous form affords still less promise of cure: the
unsatisfactory results of treatment are generally acknowledged.
During an attack of dysmenorrhoea the patient should remain in bed for
the benefit of rest and warmth. In those cases where the flow is not
too free, and especially when relief follows its appearance, active
measures to promote this end may be instituted by hot drinks and hot
fomentations. In married patients a hot sitz-bath, during which the
vaginal syringe is used to douche the uterus, is an efficient measure.
Pain being the prominent symptom, and remedies for its relief being at
hand and reliable, the indication is clear and the treatment can be
briefly stated. In execution, however, it is not a simple problem:
immediate relief is not alone to be considered. If opiates be resorted
to for frequently-recurring pain, a habit will soon be formed that is
no less a calamity than the disease itself. While, therefore, opium and
its preparations are reliable remedies, and in many cases
indispensable, they should be administered as seldom and as sparingly
as possible, and always with an appreciation of possible injurious
consequences. Many cases can be successfully managed with chloral
hydrate, or belladonna, or Indian hemp. When opiates are resorted to,
they should be combined as much as possible with other medicines by
which their effects are modified, and relief afforded with the smallest
possible dose. Thus in cases attended with vascular excitement these
ends may be attained by the union of opium with tartar emetic or
aconite; when there is marked disturbance of the nervous system, it may
be combined with an antispasmodic, as the compound spirit of ether.
Administration by the rectum will produce a local as well as a general
effect, and injections of starch and laudanum or suppositories of opium
and belladonna may be administered. The speediest and most certain
relief is afforded by the hypodermic syringe. Resort to it should,
however, be rigidly controlled; it should be used as a miser uses his
gold, and it need scarcely be added that only very exceptional, if any,
circumstances will ever justify placing the syringe in the hands of
friends or attendants, no matter with what restrictions. Unfortunately,
this is sometimes done, but very rarely without great injury resulting.
During the intervals general treatment should be instituted according
to the indications. All functions at fault are to be regulated. Anæmia
is to be corrected, the debilitating effects of malaria counteracted,
good digestion promoted, and a weakened nervous system strengthened.
These indications are met by tonics in various forms, notably iron and
zinc; by antiperiodics, as quinia and arsenic; by stomachics; and by
the judicious use of wine. There are other remedies quite as useful as
drugs--cold sponging and shower-baths, followed by vigorous rubbing,
general electrization, and, when the patient cannot or will not take
outdoor exercise, massage. Change of scene and air is sometimes
beneficial or even necessary. In many cases of pronounced neuralgic
form, or in which the nervous system has been shattered by the severity
or long duration of the attacks, there can be but little hope of
amelioration without a thorough change of habits and mode of life in
every respect.
The local treatment will be according to the conditions present. In the
{199} obstructive form, polypi are to be removed if present, and in
stenosis the patency of the canal restored. Dilatation may be
accomplished by tents. Should these fail, resort may be had to surgical
measures, as the frequent passage of bougies gradually increasing in
size, forcible dilatation with steel dilators under an anæsthetic, or
by incision. Each of these measures has its advocates, and with all
cures have been effected. Flexions should be corrected as far as
possible by a vaginal pessary. Intra-uterine pessaries more certainly
correct the deformity, but great care should be exercised in their use.
If inflammation be present, uterine or pelvic, they will not be
tolerated or will do positive injury; nor should a patient with any
instrument of this kind ever be allowed to pass out of reach of the
physician unless she can herself remove it.
The treatment of many cases of congestive dysmenorrhoea is very similar
to that of suppressed menstruation from cold--warm drinks, hot
foot- and sitz-baths, fomentations, and douches.
Particular attention should be paid to the bowels, not alone to correct
constipation, but to give full relief to a clogged portal system by
saline purgatives. If there be prolapsus, a pessary should be adapted
so as to keep the uterus up in its place; by this means passive
congestion is much relieved. Bromide of potassium is a reliable remedy
as a corrector of pelvic congestion. In the congestive cases of anæmic
subjects iron will act beneficially; in inflammatory congestion it does
injury. Dysmenorrhoea dependent upon hyperplasia or endometritis should
receive the treatment appropriate to those affections.
In neuralgic dysmenorrhoea the general treatment is far more important
than the local. All those hygienic and therapeutic measures already
detailed should be faithfully persevered with. For the relief of pain
and control of the nervous symptoms enemata of asafoetida are useful.
Chloral may also be administered in the same way or by the stomach,
with camphor, valerian, and the æthers as required. In this form apiol
has been successfully used; the evidence as to its value is clearer
than the explanations of its mode of action. It may be given in
capsules, each containing five grains, one, two, or three daily.
Some local measures often render good service: among them is the
passage of bougies, which sometimes modify the sensitiveness of the
cervical canal, as they do that of the male urethra. The galvanic
current, both continuous and Faradic, has effected cures, but the cases
to which it is best adapted or in which it is most likely to be good
cannot be clearly indicated. A galvanic stem-pessary may be used,
observing due caution. This instrument has been modified and much
improved by Thomas: being made like a string of metallic beads, it is
extremely flexible, and many of its former objectionable features are
removed.
A successful treatment of membranous dysmenorrhoea has not yet been
promulgated. The great difficulty of its cure is admitted by the
highest authorities. Some cases associated with stenosis of the cervix
have been cured by dilatation--a fact which but strengthens the general
principle of correcting all anatomical changes whenever possible.
Strong caustics have been applied to the interior of the uterus with a
view of exerting an alterative influence upon the seat of the disease.
The course seems correct in theory, but in practice it has not proved
fruitful of good results, and treatment in the majority of cases is
limited to palliation.
{200} In regard to marriage in females afflicted with dysmenorrhoea, it
may be stated to be advisable in many cases of the neuralgic form and
in anæmic subjects where the flow is so scanty as to border on
amenorrhoea. In cases of the congestive form, if dependent on
inflammation or on organic lesions, as fibroids, there is very great
probability that the symptoms will be aggravated by this radical change
of mode of life.
Menorrhagia.