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38 Bishop St

DISCUSSION ON DYSMENORRHCEA.

F. A. L. LOCKIIAKT, M.B. (Edin.)

Assistant Demonstrator of Gyna'cologj-, McGill University ; Assistant Gyntecologist
to the Montreal General Hospital ; Gynrecologist to the Verdun
Hospital for tlio Insane.

Reprinted ^ from the Montreal Medical Journal, March, 1897.

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DISCUSSION ON DYSMENORRHCEA.'

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, ■/." ","; ' THE TREATMENT, ';,,•' ^'V '/".''.■ i',

F. A. L. LocKHART, M.B. (Edin.)
Assistunb Demonstrator of Gynoicology, McGill University ; Assistant Gynecologist
to the Montreal General Hospital ; Gyneecoiogist to the Verdun
Hospital for the Insane. \ •"

Treatment of Dyamenorrhoea. — The treatment of dysmenorrhcea is
such a wide subject that one can only rapidly run over some of the
different forms without fully advancing arguments for or against any
one particular kind in the time at our disposal.

In considering this question, we must keep before us the fact that
dysmenorrhcea is merely a painful manifestation of some abnormal
condition of either the body generally or one or more of the pelvic
organs, and that, in order to cure the symptom we must cure the
cause. Thus our first steps should be directed towards discovering
that cause. The physician who blindly treats dysmenorrhcea by a
routine course of sedatives, without thorough investigation of the case,
is doing justice to neither his patient nor himself. The routine use
of this class of drugs is to be most strongly deprecated as they in time
do positive harm in making patients their slaves and undermining
their nervous system. Of course if one is called in to see a patient
who is in the midst of a most acute attack of pain, an hypodermic of
morphine is often absr' itely necessary, although much may be gained
by the application of heat to the hypogastrium and • dose of 10 grs.
of antipyrine or phenacetine repeated twice if necessary with an
interval of one hour. Alcohol acts like magic in relieving the major-
ity of cases and it is largely used (far more largely than one would at
first think) by women, but it should be utterly prohibited as the habit
is very apt to grow on one and it really increases any local trouble
which may already exist.

A great deal may be done to prevent the occurrence of dysmenorr-
hcea by care of the growing girl. I think that it is the experience of
the older physicians, that dysmenorrhcea is growing more and more
common, and this is to a great part due to the carelessness and ignor-
ance of parents who do not know the extent of the injury that they
are doing to their daughters by urging them to excel at their studies.
As they approach puberty, girls should , have freedom from all kinds
of excessive work. They should be encouraged to go into the open
^ Read before the Moutree^l Medico-Chirargical Society, Dec. 18, 1896,

air and take as much exercise as is possible without actual fatigue.
Instead of their brains being used, it should be their limbs, except just
before and during menstruation, when they should be kept quiet, at
all events until regular menstruation has set in. They should keep
regular hours and their diet should be nourishing but simple. The
girl ought not to be kept in ignorance as to what she should expect
at puberty through any false modesty on the part of the mother. As
a consequence of this want of knowledge, I know of at least one case
where a young girl was just beginning to menstruate for the first time
but, only noticing a stain of blood on her underclothing, went in bath-
ing. She was attacked by pelvic peritonitis and has ever since
suffered from dysmenorrhoea.

Once menstruation has become fairly established, we may relax our
rules to a great extent, but there are f6w women who ought not to
take especial care of themselves one week out of every four of their
sexual life. ' • - " ' - '

After this trouble has been once set up, what are we to do for its
cure or relief ?

In the first pleu;e, we must take the patient's personal equation into
consideration if we hope to do her much good. Is she inclined to be
neurotic or too introspective ? If the latter, prescribe some regular
occupation for her, but it must be one which will keep both mind and
body occupied. In addition, you may prescribe a placebo or some
simple tonic for her. If she is neurotic, advise some open air exercise,
change of scene and the administration of nerve tonics. An excellent
combination for these cases is one containing arsenic, valerianate of
zinc and nux vomica, either in solution or pill.

Where the patient is a young girl just beginning to menstruate,
you will often find that she is chlorotic, in which case this disease
will require to be dealt with, and it is wonderful what an improve-
ment in the pelvic condition can be effected in these cases by the
judicious use of fresh air, wholesome diet and regular "jxercise and
rest, combined with iron tonics. One of the best of these latter is
Blaud's Pill with arsenic, although the compound syrup of the phos-
phates (Easton's), is also very useful. The condition of the bowels
should be watched, the constipating effect of the iron being overcome
''yy nux vomica, cascara, etc.

Under no circumstances should a local pelvic examination be made
in these cases until you have conscientiously employed general
remedies, and the girl should be encouraged to make as light of her
trouble as possible, as an injudicious word of discouragement may
convert her into one of those miserable neurotics, who wander from

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doctor to doctor without relief and finally fall into the hands of
charlatans and quacks.

If the above methods fail after thorough trial, it will be necessary
to make a thorough pelvic examination per rectum. The condition
usually found will be one of mal-development of the uterus, and this
must be corrected by attention to general nutrition and local measures.
One of the best of the latter is the application of galvanic electricity,
which may be applied by placing one electrode over the sacrum and
the other over the pubes, or, if this fails after thorough trial, the
sacral electrode may be replaced by one in the vagina.

Pelvic massage has been highly recommended by some tor this
variety of dysmenorrhoea (which one might call "developmental"),
but I think that its utility is doubtful. For one thing, it is extremely
difficult to employ it effectively on account of the abdominal walls of
a nullipara being usually so tense, and, secondly, the necessary mani-
pulations are apt to direct the patient's attention to her genitals.

The bicycle is a most useful assistant in this class of cases, but its
use must be very carefully regulated. It acts, of course, by stimu-
lating the general and pelvic circulation and also as an encouragement
to take exercise in the open air. :

In congestive or injlammatory dysmenorrhcea, the indications are,
first, to discover the cause, and, secondly, to remove it. For example,
a small sub- mucous fibroid of the uterus may partially block up the
canal and cause congestion of the endometrium, which swells up and
causes the pain at the menstrual periods. Here the indication is to
remove the diseased endometrium, and this may best be done by
thorough curettage. The application of the positive electrode of a
galvanic battery is also an efficacious remedy, although, naturally, the
treatment will require to be more prolonged than where \>ae curette
is used. A slower, but sometimes a surer, way of removing the
diseased tissue is to use gradual dilatation and the application of
iodine, iodized phenol or pure carbolic acid to the interior of the
uterus. If the uterus is out of position, you must endeavour to
replace it and maintain it in its normal situation. If this cannot
be done on account of adhesions, these may be softened by using
the hot douche, by glycerine tampons and the application of iodine
to the vaginal fornices. These methods will relieve the congestion
as well as soften the adhesions. In the majority of theso cases
the uterus will be found to be prolapsed, in which event the wearing
of a pi'operly fitting ring pessary will give great relief by supporting
the uterus and ovaries and so relieving the congestion, and it is under
these circumstances that tha much abused pessary will most strongly

prove its right to a place in gynrecological treatment. You should
deplete the uterus and whole pelvis and try to restore the vessels to
their normal condition. The flow of blood through the uterus may
be lessened by giving ergot, hydrastis, viscum album, quinine and the
like, all of which have a marked effect in causing contraction of the
muscular fibres of the uterus.

Promote the activity of the bowels by salines for a few days and
then keep them regular by cascara, liquorice powder, etc.

Moderate exercise such as walking or bicycling wi'l be found of
great service, this being so much better than carriage exercise_ on
account of the effect the movements of the limbs have upon the pelvic
blood supply. Some of the movements recommended by Thure-
Brandt are also very useful in the same manner. The beat are rota-
tion of the limbs, their flexion and extension against resistance and
rising and falling on tip-toes. All of these procedures determine the
blood from the pelvis where more or less stasis has occurred, and
cause it to flow more freely through the limbs and pelvis.

Locally, where the uterus itself is the seat of the congestion, much
may be done by the extraction of blood from the cervix by either
leeches or scarification. Boroglyceride tampons, galvanism, the appli-
cation of iodine to the cervix and fornices, the judicious use of the
sitz-baths (especially where the flow is slight) and the hot douche are
also distinctly serviceable where you desire to reduce pelvic conges-
tion. In an acute case, the application of hot stupes or else an ice-bag
over the pubes will give great relief, as does also the application of a
blister over each ovarian region.

A most useful form of treatment is gradual dilatation of the cervix
by Hanks' dilators, etc., as was previously mentioned in connection
with those cases complicated by the presence of a submucous fibroid.

Membranous dysmenorrhoea is probably a modification of the con-
gestive or inflammatory form. Fortunately for suflering woman this
is one of the rarest varieties of painful menstruation. It is also the
most diflScult to cure. Numerous methodt. of treatment have been
instituted and highly recommended for this trouble, but that method
which will cure all cases has still to be discovered.

One of the most highly praised methods is thorough cauterization
of the interior of the uterus with the positive electrode of a galvanic
battery, and this will doubtless cure many cases, especially if seen
early.

Curretting, with or without the application of strong caustics, has
many adherents, but, in the majority of cases, the membranes re-
organize before ■ many months elapse. Beamy, of Chicago, reports

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the cure of three patients by the following decidedly drastic method
of treatment. Five days prior to one menstrual period, he thoroughly
curretted the uterus, using first a sharp curette and then an inflexible
one of dull wire. The cavity is then thoroughly cleansed by swabs
of cotton moist-ened in a 1 per cent, solution of carbolic acid. This
latter solution is then replaced by one of 2 J per cent, of the same acid,
at least twenty applications of this stronger solution being made at
the one sitting. A loosely rolled wad of iodoform gauze is placed in
the vagina and the patient is returned to her bed, having an ice-bag
over the hypogastriiim. The menstruation now due is generally
missed. The patient receives a similar treatment, except that the
sharp curette is omitted, fourteen days after the first operation and
two other curettings with the dull curette, followed by the application
• . ^, of the acid, etc., at intervals of from fourteen to seventeen days, the

. - amount of tissue which could be removed being less and less each

. . time. In the first case, the menstruation was normal after the third
month from beginning treatment. The patient became pregnant soon
- after a id was quite well after delivery. The second patient had one

relapse, which was cured by one more course of treatment, while the
<- third required but the one course. ■ ,•»;;;

y Duke treats membranous dysrnenorrhcea by scarifying the cervix

' / three or four times weekly between the ^-^eriods. Just before

' menstruation begins, he thoroughly curettes the uterus and introduces

'■■'.'■}, ■ a spiral wire stem pessary into its cavity. This is worn for three

or four months, the patient taking daily hot douches, even during
the flow. This, however, is rather risky treatment, as one cannot
always watch the patient as closely as one would like to when she is
. wearing a stem pessary. His objects evidently are to deplete the

uterus, remove the diseased mucous membrane and allow of free
drainage of the uterine cavity, so that the tissue may not form again.
The spasmodic form of dysmenorrhrea depends in many cases upon
constitutional conditions, such as strong neurotic tendencies, and can
often be cured by drugs, one of the first indications being to restore
1';'^. * tonicity to the nervous system by arsenic, nux vomica, zinc, etc*

Anti-spasmodics are indicated just before the period approaches, and.
as there is often more or less anaemia present, iron and chlorate of
potash may be added with benefit. A favourite prescription of my
former teacher. Dr. J. Halliday Groom, is for a mixture containing
actsea rocemosa, perchloride of iron, chlorate of potash and serpen-
t'lria, and I can bear witness to its undoubted efficacy in many cases.
Olliver gives a combination of ammonium, potassium and sodium
bromide nightly for one week midway between two periods and then

5 grs. of antipyrine every hour for six doses, if ntcessary, as soon as
the pains are felt. He also recommends hot hip-batns when the dis-
charge is scanty.

Cannabis Indica is a favourite drug to give and is especially usefu'
where menorrhagcea is present. Nitro-glycerine, nitrite of amyl and
viburnum are also highly recommended Depletion of the pelvis is
indicated anu may be carried ouo just as with the other varieties.

Anti-spasmodics may be applied locally to the cervix with advan-
tage. This was practised in olden times when the patients were
instructed to squat down over a basin of burning herbs, at the same
time as they dilated the vagina by their fingers. Sir James Simpson
used to employ the vapour of carbonic acid gas, either alone or com-
bined witli that of chloroform. The gas was formed by putting
equal parts of tartaric acid and bicarbonate of soda into a bottle
with a little water. It was then conducted into the vagina through
a pipe.

In the majority of the cases of spasmodic dysmenorrhcDa, there is
anteflexion, with consequent endometritis and a certain amount of
stenosis of the uterine canal, and these must be corrected before much
relief can be obtained. This may be effected by dilatation of the
cervix, either forcibly, by Goodell's or Sim's instrument, or else
gradually, or, as some recommend, by dividing the cervix.

Dilatation is one of the oldest methods of treating stenosis of the
cervix, Hippocrates stating " that where the orifice is very much con-
tracted, it must be opened up with bougies or leaden instruments," It
is also one of the best methods in the class of cases which we are
considering. Many prefer forcible dilatation under an anaesthetic,
thoroughly curetting the uterine cavity and inserting an intra-uterine
stem pessary at the same time. I'his is undoubtedly good, but it is
not always advisable to alarm the patient with the idea of an oper-
ation, when a similar or even better result may be obtained without an
antesthetic and with but little pain ; I refer to gradual dilatation
with graduated bougies, as has been described elsewhere. This
•method is practically painless, if properly carried out, is continuous
and very effectual, several cases having been cured by it in my own
practice.

The use of tents dates back at least two centuries, mention being
made of them in a book written in 1676 by Van Roonhuyse. He
used tents made of " gentian radix, medulla sambucii, or even by a
prepared dry sponge, having been first moistened in melted white
wax and squeezed in a yness to make of it convenient pessaries,
according to the exigencies of the case, by which means the neck of

the womb can be di-»c!'>8ed and widened and made to have its due
purgations." He goes on to say that the patii'iit may be made to
wear an instrument (evidently a stem pessary) made of silver, 'vory
or horn, and prefers this treatment to divulsion of the cervix by the
knife.

Most gynaecologists are opposed to the use of tents as they are apt
to produce sepsis and pieces may become broken off and left inside of
the cavity, ftut Poulet and Fraipont strongly recommend their use on
account of their softening effect upon the tissues. They employ lami-
naria tents which have been preserved in a saturated solution of iodo-
form in ether, as they are then antiseptic and pliable. This it
followed, where necessary by forcible dilatation, which looks as if the
advocates of the tent had not very much faith in it themselves.

Electrolysis is employed to overcome the stenosis by some, a bul-
bous pointed electrode being used. High currents are to be avoided,
one of from eight to ten milliaraperes being all that is necessary.

Many writers say that it is impossible to cure spasmodic dysmen-
orrhcea by dilatation, on account of the uterine canal again closing up,
but Hovvard Kelly says that it, will cure forty per cent, of the cases.
He refers to forcible dilatation, and, while I can give no actual statis-
tics, I feel confident that gradual dilatation will produce as good
results.

The old method of divulsion of the cervix, as practised by Simpson,
is not to be recommended. He held that the chief .seat of the trouble
lay in fibres around the external os and began to make his incision
below the internal os, cutting right through the cervix at its lower
extremity. If you are going to use the knife at all (and it is necessary
every now and then), your best way will be to make several nicks
through the fibres at the internal os, as it is these which contract and
cause the spasm. The canal may be kept patent bj' strips of gauze or
a stem pessary. As for Dudley's operation, where a wedge-shaped
piece of the cervix is removed, I consider it wrong in principle, as you
establish a condition, which, when caused by parturition, frequently
calls for operation. I refer to laceration of the 'cervix. If in the one
cose, this sets up a chain of symptoms requiring operation, why will
it not do so in the other ?