The customary classifications which can be verified by anyone with a few years of practical experience are, for the most part, satisfactory, but the writer has adopted the following as the results of his experience, viz.:— 1. Dysmenorrhoea from congestion.
2. Dysmenorrhoea from obstruction.
3. Dysmenorrhoea from neuroses.
4. Dysmenorrhoea from endometrial hypertrophy.
1. Dysmenorrhoea from congestion. This is the simplest of all the varieties. Congestion is always and necessarily a feature of menstruation; that is, the cur rent in the pelvic vessels is then more rapid or the tension or volunae is greater, or perhaps all these elements are com bined. When the degree of this con gestion is greater than can be readily tolerated by the person, pain is one of its results (the other results need not concern us now), and this pain will last as long as the congestion continues, and will recur as frequently. Tolerance of this condition to a greater or lesser ex tent is acquired by many women, just as other disagreeable experiences become tolerable when habitual and inevitable. In some cases the pain seems limited to one or both ovaries, in others to the uterus, and in others it seems to be dis tributed through the pelvis.
2. Dysmenorrhcea from obstruction. There has been much discussion for many years concerning this variety, some writers going as far as to say that the vascular system of the pelvis was so ac commodative that dysmenorrhcea from obstruction was not possible. Clinical facts do not warrant such a statement. Obstruction of the outflow of blood is, perhaps, not so great when the womb is flexed backward or forward as was claimed a few years ago by Sims, Hewitt, and others, especially if coagulation of the blood within the uterus does not oc cur; but, if such coagulation does take place (and in some cases also in which it does not), dysmenorrhoea will be a very pronounced symptom.
With stenosis of the cervical canal the same difficulty to the outflow of the menstrual product is also frequently ob served. With imperforation of the hy men or of the os internum or externum obstruction to outflow is complete. A certain portion of the transuded blood is reabsorbed, but the remainder persists, distending the vagina or the uterus or both, sometimes producing a very large tumor, and invariably resulting in great pain, which in some cases has led to a fatal result.
Pain from incomplete development of the pelvic organs, especially the uterus, is also to be referred to obstructive dys menorrhcea as its origin, and, as in cer tain cases of congestive dysmenorrhcea, the bad symptoms are not limited to pain. Dysmenorrhcea from inflamma tory exudate is an acquired symptom, the exudate binding the pelvic organs into a more or less firm mass, which tends to become firmer as the contraction, which time brings with it, takes place. The
pain in such cases is not limited to ob struction to outflow; indeed, there is no such obstruction apparent in some of the cases, the flow being profuse in some in stances and scanty or absent in others. The remarks concerning inflammatory exudate will also apply to scar-tissue, which, by its presence, will often effectu ally obstruct the passage of the menstrual blood-current. To this variety of dys menorrhcea might also be added those cases which are so often seen that de pend upon perverted or imperfect nutri tion and in which constipation is an ever-present accompanying symptom.
3. Dysmenorrhcea from neuroses. There may be at least two types of this variety; in one of them the neurosis is the sole discoverable source of trouble, in the other it is secondary to disease of some other character within the pelvis.
Hysteria is at the foundation of many of the cases of the first-mentioned vari ety, the pain connected with menstrua ation being, to a great extent, simulated or imagined.
When we realize, however, the inti mate anatomical relations which the sym pathetic nerves of the pelvic organs bear to the nerves and ganglia of the rest of the organs of the body, we are quite pre pared to believe that painful sensations in those organs might be transmitted to the organs of the pelvis. So far as I know there have been no exact investigations upon this subject. The referred or re flected pains from the pelvic to the other organs have been much discussed and a variety of conclusions has been reached. The neuroses in the pelvis or pelvic organs which occasion dysmenorrhcea may constitute a use of language which is somewhat misleading. Of course, all pain is the evidence of nerve-irritation or a neurosis. The form which is here to be considered is that in which, aside from mere congestion or obstruction as an at tendant of the menstrual experience, there is a direct irritation of nerve-tissue which is not apparent apart from the menstrual epoch. Such, for example, is the case when the unusual pressure due to the congestion of menstruation is ex perienced by the sacral nerves as they pass through the pelvis, the tissues being already the seat of inflammatory exudate. The tissues are squeezed and contracted by this exudate; but the addition of the menstrual congestion introduces a further element of press ure, which causes irritation of the nerves which are infringed upon, and pain is experienced, which radiates in the di rection of the imprisoned nerves. Tbis condition is not infrequently found in insane women; it is probably a factor in producing insanity, and such insanity cannot be expected to ameliorate perma nently until the source of trouble is re moved.