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 38 Bishop St 
 
 DISCUSSION ON DYSMENORRHCEA. 
 
 BY 
 
 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.' 
 
 \' ' ' ,. ~ ' -.■ 
 
 , ■/." ","; ' 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, 
 
 
2 
 
 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 
 
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 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 
 
 
 
e 
 
 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 ?