CLINICAL ASPECTS OF
SOME
DYSMENORRHEA.1 BY
R.
S.
S.
Statham, O.B.E., M.D., Ch.M.,
Honorary Gynaecologist, Lecturer
on
Bristol
Royal Infirmary ; University of Bristol.
Obstetrics in the
It is
probable that dysmenorrhea, in a more or less degree, is one of the very commonest of the physiological in modern civilisation. It is most unusual to find menstruation occurring without some errors
which
occur
of
pain or unaccompanied by unpleasant molimina. I, personally, know of two cases only, and they regard themselves as unusually fortunate. This condition is intimately connected with modern civilisation. Cameron points out that in large cities
degree
"
"
30 per cent, of women suffer considerable discomfort during the menstrual period, and a very practical reason has been advanced by Professor Tuffier. He states that menstruation is not all.
In
must
be
a
savage and a
in
rarity
marries very young, and then becomes
fifteen months
truly
a
normal function at
natural state this event
any individual.
sees
perhaps
one or
The
pregnant.
The
woman
two
periods,
next
twelve
to
occupied in pregnancy and lactation, and then possibly one more period occurs before the are
next pregnancy, 1
A
Society 187
so
that?as the menopause
Paper read at a Meeting April 13th, 1927.
on
of
the
Bristol
comes on
Medico-Chirurgical
Dr. R. S. S. Statham
188
early?the so
woman
in her life.
entirely
only
menstruates
In modern civilised
a
dozen times
or
the
is
Europe
case
different.
Before
discussing dysmenorrhoea,
it is necessary
to remember the normal mechanism of menstruation.
the last few years a great amount of research been undertaken 011 the menstrual function.
During has
Shaw, Marshall, and Beckwith Whitehouse, Novak and Schrceder have published many papers, and recently Beckwith Whitehouse has authoritatively summarised the latest views. He states that menstruation is the abortion of the decidua of the
uterus ;
non-pregnant
the menstrual flow corresponds with the failing of the corpus luteum when the ovum is not fertilised, and is " " of a menstrual abortion. This view is lochia the I
think, and this is in keeping with the French view that I have quoted, for surely a decidual abortion cannot be regarded as normal. With this conception of menstruation, it is hardly surprising that it should be so frequently complicated by pain now
universally accepted,
and
difficulty.
There
are
three
main
types of dysmenorrhoea
described, and I wish to draw attention type which I find to be very common. These
to
a
fourth
are :?
1. The
intrinsic
type of Blair Bell. 2. The congestive or extrinsic type of Blair Bell. 3. The membranous type. 4. The mixed type. The proper recognition of each type makes all the
spasmodic "
difference to the 1.
or
"
principles
of the treatment
required.
Spasmodic Dysmenorrhoea is easily diagnosed The patient gives a history that the pain as a rule. the first period and has been present at with began
Some Clinical Aspects
every period since.
type, even
sometimes
faints.
The
so
The
of
pain is
severe
Dysmenorrhea 189 acute and
that the
pain begins
patient
before the
colicky
in
vomits
or
flow, and is
usually much better when this has been established twenty-four hours or more. The loss is almost always scanty and irregular, and between the periods there is usually no discomfort. If the
patient be examined, in
ill-developed "
most
uterus will be found.
cases a
small,
Frequently
it is
i.e.
acutely anti-flexed, and may also be retroverted ; in the angle made by the cervix and body irregular masses of muscle tissue are developed, and Cameron lays much stress on the consequent spasm cochleate,"
of the internal to
In these
os.
"
pinhole os." capillary tube, and
which will admit
Blood could
cases
can
the
pain is
pass up
certainly get
a
not due
ver}r small a cervix
out of
The pain is due to irregular malformed uterus, i.e. to muscular " intrinsic." cramp, and is truly
contraction of
2.
a
sound.
a
In the
second, the congestive or extrinsic type, on the other hand, the history is that of a girl having normal
periods
for
some
time, when
is dull and
painful. The pain pain is localised
the
aching,
they
become
the flow
profuse,
to the back and
"
"
drags down these into the pelvis. Between periods the pain is to a less degree. On constantly present, though to find it usual the examination is uterus large and often fixed in
a
position of retroversion. The fornices
are
tender and often the ovaries and tubes are enlarged and palpable ; in fact, there is a typical pelvic peritonitis.
Further inquiry will elicit the fact that about 50 per cent, of these cases follow a confinement or miscarriage,
and, in many of the remainder, appendicitis
ascending
infection will be described
as
a
or
an
precursor
Dr. R. S. S. Statham
190 of the trouble.
being
organs much
worse
Here the
pain
is due to the
surrounding
adherent and inflamed, a condition made by the normal pelvic congestion of
menstruation. 3. Membranous clysmenorrhoea is
a
very rare condition. case, in which the
Personally I have only seen one patient passed a large bolus-like
cast
of
the
endometrium. I imagine the pain was really due to obstruction, similar to that occurring when a polypus The cause is probably is extruded through the os. failure in the ferment which the break up of the endometrium. due to
4.
a
The mixed
normally
causes
is, to my mind, very common. prevent a girl with true intrinsic
case
nothing to spasmodic dysmenorrhea becoming infected with the I gonococcus or getting an attack of appendicitis. have operated on many such patients from whom my surgical colleagues have removed a suppurating appendix a j^ear or so previously, and it has been the supervention of the extrinsic on the already existing intrinsic pain that has induced them to undergo a There is
further seen
operation.
when the
The
question
importance of this will be of treatment is considered.
Treatment. It is
probable that greater strides have been made
in the treatment of this condition than in any other gynaecological disease. The best indexes of this are the statements of medical officers in charge of large girls' schools.
I
was
told
by
one
such doctor that
twenty
years ago 75 per cent, of the girls had two or three days off work every month, and now only 10 per cent, were This is surely a remarkable improvement. so excused. The treatment must be considered under each of
case.
type
Some Clinical Aspects
Dysmenorrhea 191
of
Spasmodic Dysmenorrhcea. In this condition an amount of good can be done by moral suasion. The girl must be encouraged not to consider enormous
Exercise, the quieter games, and? above all?hot baths, will, in most cases, enable her to carry on her normal school life, and frequently the symptoms improve out of all knowing. This is due, I think, partly to development and education of the faulty uterus, and partly to the training in disregarding an unpleasant symptom. The latter factor is probably herself
an
invalid.
powerful
more
psychiatrist
dysmenorrhea This
seems
am sure
really little
than is
told to
could me
imagined,
that
me
be
all
an
eminent
of
spasmodic by psycho-analysis.
cured
to be rather
and
cases
strong claim, but I
a
that it is well founded.
Should the
pain
be
severe, it will be found that rest in bed is very
but is convenient in view of the mental
good,
disturbance caused in
patient. The coal tar and allied products, e.g. aspirin, ammonal, etc., are a great help, and I have had several great successes with benzyl benzoate 20 per cent, in alcohol, combined with small doses of chloretone to prevent vomiting. It is a
very young
unnecessary to state that morphia is more than dangerous for this type of patient. When I was house physician at Bethlem
I
Royal Hospital
saw
numbers of
patients
who had become addicts from being given morphine or heroine for this condition. If these methods fail, I do not think it wise to leave the patient too long before
resorting inevitable
to
The
operation.
pain
is very
and she dreads its
effect
great in
monthly
a
of
severe
child of 15
or
and
16,
and more, this point. In
recurrence more
and may become completely neurotic on 75 per cent, of cases a complete cure can be obtained
by dilating operation
the cervix to
has fallen into
14
Hegar. disrepute, and
This I
am
simple certain
192
Dr. R. S. S. Statham
that the
cause
is that it has been done
of
It is
wrong type dysmenorrhea. dilate the cervix if the patient is chronic
appendicitis
sees cases so
done In of
quite useless
suffering
from
to a
salpingitis, yet every day dysmenorrhea which have been one
often told that " dilating has case where it was never indicated.
am
good" in a spasmodic dysmenorrhea dilators straightens out the anti-flexion no
true
a
often for the
or
of extrinsic
treated, and I
so
the
passage
and
ruptures
the abnormal muscle
masses about the internal os and and instant usually lasting relief. It is most produces the that dilating be done slowly and carefully important to avoid lacerations, or, as pointed out by Dr. Drew
Smythe, the resulting scar tissue will cause a recurrence pain in an aggravated form. In all these cases I administer thyroid gland in hope that it will aid the uterus to develop to a proper extent, but I find it hard
of the
to say if it is very efficacious. If this treatment is useless, it is difficult to know
what to do. in
I have
unmarried
an
done a subtotal hysterectomy of 31, whose life was a misery much improved, and very grateful, once
woman
to her.
She is now but I think it is a barely
justifiable operation,
to be resorted to in extreme cases, in over
30 and
unlikely
women
and
only
who
are
Two other methods are results claimed, viz. sympa-
to marry.
described and very good thectomy of the plexus
the sheath of the " " internal iliac artery, and section of the pelvic nerve I have no personal on the fourth lumbar vertebra. are
The extrinsic
really
The
but the
encouraging.
cases
Here the
treatment.
hot
on
of either method of treatment,
experience
results claimed
with.
lying
need cause
quite
a
different line of
must be found and dealt
majority of cases do very well on aperients, douching carried on for a quarter of an hour
Some Clinical Aspects
of
Dysmenorrhea 193
I do not least, and rest in bed during the flow. find tampons much use, and they often cause pain by pressing 011 the swollen pelvic organs. Hot antiphlogistine tampons are useful, but require a skilled nurse at
to insert them.
few weeks' treatment on these lines will improve the patient so much that she will not worry about her dysmenorrhoea, but if she does not get better fairly soon, it is necessary to open the abdomen and deal with the pelvic adhesions and which
displacements the
appendix
Usually
dysmenorrhoea, pelvic peritonitis
I believe
the root of the evil.
to be the most
of
82
are
a
of this type frequent and in a series of 150 operations for I found it more or less involved in cause
cases.
It is obvious that in the orrhoea both
operations
bad
are
to warrant
enough disappointing to are
return in five
or
"
"
of dysmenmixed type necessary if the conditions
operation
at all.
It is most
open an abdomen and have the patient six months and tell one that the back-
ache is gone, but that she still gets the colic or vice versa. now do both operations at one sitting, and the dilating
I
must be
done first.
suspension
is
If
performed,
a
Gilliam
it is almost
or
similar ventroto
pull efficiently afterwards. change of gown and gloves during impossible
down the cervix and dilate it
This, of the
course, entails
operation, For
the
treatment
mended
by
but it is well worth it in results. meinbranous dysmenorrhoea no
has
been
some
and
efficient
devised.
Curettage is recomgland therapy by others. My
experience of one case is quite useless to me to help form an opinion. She did not improve 011 any treatment at all, and finally had her uterus removed own
by somebody like to
else.
aspect of this complaint that I should stress, namely the great importance of spasmodic
There is
one
194 Some Clinical Aspects
of
Dysmenorrhea
about the time of the menopause, when present before. It is frequently the
dysmenorrhea
it has not been
sign of carcinoma of the body of the uterus, that organ trying to expel the growing mass in its interior, and so causing the colic. It is also the typical earliest
symptom of that interesting tumour, the endometrioma or
adenomyoma.
the ovaries
Here endometrial
other
grafts
or
rests in
found to contain
pelvic organs hollow cavities into which menstrual blood is effused when the uterus menstruates. This blood being under or
great tension
are
colicky dysmenorrhea. It about the menopause, and I have twice mistaken the condition for a tubal pregnancy. The onset of spasmodic dysmenorrhea in a woman of about often
causes severe
occurs
40 indicates
immediate curetting, and I have never doing, for a number of early carcinomata of an
regretted so body have
the
prospect of
a
been
cure.
found, and removed with every
SOME
DYSMENORRHEA.1 BY
R.
S.
S.
Statham, O.B.E., M.D., Ch.M.,
Honorary Gynaecologist, Lecturer
on
Bristol
Royal Infirmary ; University of Bristol.
Obstetrics in the
It is
probable that dysmenorrhea, in a more or less degree, is one of the very commonest of the physiological in modern civilisation. It is most unusual to find menstruation occurring without some errors
which
occur
of
pain or unaccompanied by unpleasant molimina. I, personally, know of two cases only, and they regard themselves as unusually fortunate. This condition is intimately connected with modern civilisation. Cameron points out that in large cities
degree
"
"
30 per cent, of women suffer considerable discomfort during the menstrual period, and a very practical reason has been advanced by Professor Tuffier. He states that menstruation is not all.
In
must
be
a
savage and a
in
rarity
marries very young, and then becomes
fifteen months
truly
a
normal function at
natural state this event
any individual.
sees
perhaps
one or
The
pregnant.
The
woman
two
periods,
next
twelve
to
occupied in pregnancy and lactation, and then possibly one more period occurs before the are
next pregnancy, 1
A
Society 187
so
that?as the menopause
Paper read at a Meeting April 13th, 1927.
on
of
the
Bristol
comes on
Medico-Chirurgical
Dr. R. S. S. Statham
188
early?the so
woman
in her life.
entirely
only
menstruates
In modern civilised
a
dozen times
or
the
is
Europe
case
different.
Before
discussing dysmenorrhoea,
it is necessary
to remember the normal mechanism of menstruation.
the last few years a great amount of research been undertaken 011 the menstrual function.
During has
Shaw, Marshall, and Beckwith Whitehouse, Novak and Schrceder have published many papers, and recently Beckwith Whitehouse has authoritatively summarised the latest views. He states that menstruation is the abortion of the decidua of the
uterus ;
non-pregnant
the menstrual flow corresponds with the failing of the corpus luteum when the ovum is not fertilised, and is " " of a menstrual abortion. This view is lochia the I
think, and this is in keeping with the French view that I have quoted, for surely a decidual abortion cannot be regarded as normal. With this conception of menstruation, it is hardly surprising that it should be so frequently complicated by pain now
universally accepted,
and
difficulty.
There
are
three
main
types of dysmenorrhoea
described, and I wish to draw attention type which I find to be very common. These
to
a
fourth
are :?
1. The
intrinsic
type of Blair Bell. 2. The congestive or extrinsic type of Blair Bell. 3. The membranous type. 4. The mixed type. The proper recognition of each type makes all the
spasmodic "
difference to the 1.
or
"
principles
of the treatment
required.
Spasmodic Dysmenorrhoea is easily diagnosed The patient gives a history that the pain as a rule. the first period and has been present at with began
Some Clinical Aspects
every period since.
type, even
sometimes
faints.
The
so
The
of
pain is
severe
Dysmenorrhea 189 acute and
that the
pain begins
patient
before the
colicky
in
vomits
or
flow, and is
usually much better when this has been established twenty-four hours or more. The loss is almost always scanty and irregular, and between the periods there is usually no discomfort. If the
patient be examined, in
ill-developed "
most
uterus will be found.
cases a
small,
Frequently
it is
i.e.
acutely anti-flexed, and may also be retroverted ; in the angle made by the cervix and body irregular masses of muscle tissue are developed, and Cameron lays much stress on the consequent spasm cochleate,"
of the internal to
In these
os.
"
pinhole os." capillary tube, and
which will admit
Blood could
cases
can
the
pain is
pass up
certainly get
a
not due
ver}r small a cervix
out of
The pain is due to irregular malformed uterus, i.e. to muscular " intrinsic." cramp, and is truly
contraction of
2.
a
sound.
a
In the
second, the congestive or extrinsic type, on the other hand, the history is that of a girl having normal
periods
for
some
time, when
is dull and
painful. The pain pain is localised
the
aching,
they
become
the flow
profuse,
to the back and
"
"
drags down these into the pelvis. Between periods the pain is to a less degree. On constantly present, though to find it usual the examination is uterus large and often fixed in
a
position of retroversion. The fornices
are
tender and often the ovaries and tubes are enlarged and palpable ; in fact, there is a typical pelvic peritonitis.
Further inquiry will elicit the fact that about 50 per cent, of these cases follow a confinement or miscarriage,
and, in many of the remainder, appendicitis
ascending
infection will be described
as
a
or
an
precursor
Dr. R. S. S. Statham
190 of the trouble.
being
organs much
worse
Here the
pain
is due to the
surrounding
adherent and inflamed, a condition made by the normal pelvic congestion of
menstruation. 3. Membranous clysmenorrhoea is
a
very rare condition. case, in which the
Personally I have only seen one patient passed a large bolus-like
cast
of
the
endometrium. I imagine the pain was really due to obstruction, similar to that occurring when a polypus The cause is probably is extruded through the os. failure in the ferment which the break up of the endometrium. due to
4.
a
The mixed
normally
causes
is, to my mind, very common. prevent a girl with true intrinsic
case
nothing to spasmodic dysmenorrhea becoming infected with the I gonococcus or getting an attack of appendicitis. have operated on many such patients from whom my surgical colleagues have removed a suppurating appendix a j^ear or so previously, and it has been the supervention of the extrinsic on the already existing intrinsic pain that has induced them to undergo a There is
further seen
operation.
when the
The
question
importance of this will be of treatment is considered.
Treatment. It is
probable that greater strides have been made
in the treatment of this condition than in any other gynaecological disease. The best indexes of this are the statements of medical officers in charge of large girls' schools.
I
was
told
by
one
such doctor that
twenty
years ago 75 per cent, of the girls had two or three days off work every month, and now only 10 per cent, were This is surely a remarkable improvement. so excused. The treatment must be considered under each of
case.
type
Some Clinical Aspects
Dysmenorrhea 191
of
Spasmodic Dysmenorrhcea. In this condition an amount of good can be done by moral suasion. The girl must be encouraged not to consider enormous
Exercise, the quieter games, and? above all?hot baths, will, in most cases, enable her to carry on her normal school life, and frequently the symptoms improve out of all knowing. This is due, I think, partly to development and education of the faulty uterus, and partly to the training in disregarding an unpleasant symptom. The latter factor is probably herself
an
invalid.
powerful
more
psychiatrist
dysmenorrhea This
seems
am sure
really little
than is
told to
could me
imagined,
that
me
be
all
an
eminent
of
spasmodic by psycho-analysis.
cured
to be rather
and
cases
strong claim, but I
a
that it is well founded.
Should the
pain
be
severe, it will be found that rest in bed is very
but is convenient in view of the mental
good,
disturbance caused in
patient. The coal tar and allied products, e.g. aspirin, ammonal, etc., are a great help, and I have had several great successes with benzyl benzoate 20 per cent, in alcohol, combined with small doses of chloretone to prevent vomiting. It is a
very young
unnecessary to state that morphia is more than dangerous for this type of patient. When I was house physician at Bethlem
I
Royal Hospital
saw
numbers of
patients
who had become addicts from being given morphine or heroine for this condition. If these methods fail, I do not think it wise to leave the patient too long before
resorting inevitable
to
The
operation.
pain
is very
and she dreads its
effect
great in
monthly
a
of
severe
child of 15
or
and
16,
and more, this point. In
recurrence more
and may become completely neurotic on 75 per cent, of cases a complete cure can be obtained
by dilating operation
the cervix to
has fallen into
14
Hegar. disrepute, and
This I
am
simple certain
192
Dr. R. S. S. Statham
that the
cause
is that it has been done
of
It is
wrong type dysmenorrhea. dilate the cervix if the patient is chronic
appendicitis
sees cases so
done In of
quite useless
suffering
from
to a
salpingitis, yet every day dysmenorrhea which have been one
often told that " dilating has case where it was never indicated.
am
good" in a spasmodic dysmenorrhea dilators straightens out the anti-flexion no
true
a
often for the
or
of extrinsic
treated, and I
so
the
passage
and
ruptures
the abnormal muscle
masses about the internal os and and instant usually lasting relief. It is most produces the that dilating be done slowly and carefully important to avoid lacerations, or, as pointed out by Dr. Drew
Smythe, the resulting scar tissue will cause a recurrence pain in an aggravated form. In all these cases I administer thyroid gland in hope that it will aid the uterus to develop to a proper extent, but I find it hard
of the
to say if it is very efficacious. If this treatment is useless, it is difficult to know
what to do. in
I have
unmarried
an
done a subtotal hysterectomy of 31, whose life was a misery much improved, and very grateful, once
woman
to her.
She is now but I think it is a barely
justifiable operation,
to be resorted to in extreme cases, in over
30 and
unlikely
women
and
only
who
are
Two other methods are results claimed, viz. sympa-
to marry.
described and very good thectomy of the plexus
the sheath of the " " internal iliac artery, and section of the pelvic nerve I have no personal on the fourth lumbar vertebra. are
The extrinsic
really
The
but the
encouraging.
cases
Here the
treatment.
hot
on
of either method of treatment,
experience
results claimed
with.
lying
need cause
quite
a
different line of
must be found and dealt
majority of cases do very well on aperients, douching carried on for a quarter of an hour
Some Clinical Aspects
of
Dysmenorrhea 193
I do not least, and rest in bed during the flow. find tampons much use, and they often cause pain by pressing 011 the swollen pelvic organs. Hot antiphlogistine tampons are useful, but require a skilled nurse at
to insert them.
few weeks' treatment on these lines will improve the patient so much that she will not worry about her dysmenorrhoea, but if she does not get better fairly soon, it is necessary to open the abdomen and deal with the pelvic adhesions and which
displacements the
appendix
Usually
dysmenorrhoea, pelvic peritonitis
I believe
the root of the evil.
to be the most
of
82
are
a
of this type frequent and in a series of 150 operations for I found it more or less involved in cause
cases.
It is obvious that in the orrhoea both
operations
bad
are
to warrant
enough disappointing to are
return in five
or
"
"
of dysmenmixed type necessary if the conditions
operation
at all.
It is most
open an abdomen and have the patient six months and tell one that the back-
ache is gone, but that she still gets the colic or vice versa. now do both operations at one sitting, and the dilating
I
must be
done first.
suspension
is
If
performed,
a
Gilliam
it is almost
or
similar ventroto
pull efficiently afterwards. change of gown and gloves during impossible
down the cervix and dilate it
This, of the
course, entails
operation, For
the
treatment
mended
by
but it is well worth it in results. meinbranous dysmenorrhoea no
has
been
some
and
efficient
devised.
Curettage is recomgland therapy by others. My
experience of one case is quite useless to me to help form an opinion. She did not improve 011 any treatment at all, and finally had her uterus removed own
by somebody like to
else.
aspect of this complaint that I should stress, namely the great importance of spasmodic
There is
one
194 Some Clinical Aspects
of
Dysmenorrhea
about the time of the menopause, when present before. It is frequently the
dysmenorrhea
it has not been
sign of carcinoma of the body of the uterus, that organ trying to expel the growing mass in its interior, and so causing the colic. It is also the typical earliest
symptom of that interesting tumour, the endometrioma or
adenomyoma.
the ovaries
Here endometrial
other
grafts
or
rests in
found to contain
pelvic organs hollow cavities into which menstrual blood is effused when the uterus menstruates. This blood being under or
great tension
are
colicky dysmenorrhea. It about the menopause, and I have twice mistaken the condition for a tubal pregnancy. The onset of spasmodic dysmenorrhea in a woman of about often
causes severe
occurs
40 indicates
immediate curetting, and I have never doing, for a number of early carcinomata of an
regretted so body have
the
prospect of
a
been
cure.
found, and removed with every
