DYSMENORRHCEA.
Practically every civilised woman suffers from more or less discomfot t and malaise at the menstrual epoch, such manifestations as pain and weight in the back and loins, some abdominal cramp, headache, and a general sense of lassitude being very common. When these unpleasant sensations become severe enough to merit the name of dysmenorrhcea it is perhaps difficult to decide, as we have no measure for pain, but it may be taken as a rough-and-ready rule that a woman has dysmenorrhoea when the pain associated with menstruation is sufficient to disable her for a shorter or longer time from following her usual avocations.
From what has been said above it follows that there is a whole class of cases of dysmenorrhoea in which the disability has no relation to any pelvic affection, but is the direct result of a general condition which causes the normal menstrual malaise to he felt much more acutely than it is by a normally healthy woman. Such cases may he divided roughly into a neurotic and an anemic type, and most of these cases are found in girls and young women who are still unmarried. It is in such cases wisest for the physician to ignore as far as possible the sexual organs and to avoid at first any local examination or therapy. A persevering trial should be given to measures adapted to restore the general health, chief among these being strict attention to the hygiene of diet, sleep, rest and exercise, with the administration of tonics such as Iron, Arsenic, and Strychnine, and insistence on saline aperients. (See also articles on Anaemia and on Neurasthenia.) It is often advisable to combine with these general remedies some measures more particularly adapted to the relief of the menstrual pain. One of the most useful is rest in bed, which should be insisted on at first for the entire menstrual period, and afterwards for at least the first day. The drugs most likely to be useful are aspirin in 5-to gr. doses repeated if necessary, phenacetin in 5-gr. doses repeated at intervals of 2 hours for three doses, apiol in I-gr. capsules every 3 hours, guaiacum in lip-gr. powders three times a day for a few days before the menses are expected, tannateof cannabin 2 to 4 grs. three times a day for a week before the period, bromide of soda 4o grs. administered per rectum in half a pint of warm saline solution. The two things to avoid are alcohol and opium, but in the worst cases a hypodermic of morphia may be indispensable. A hot bag to the abdomen is often useful, so is a hot water and mustard footbath. Blisters to the spine have also been recommended.
When a fair trial has been given to these remedies without any relief being afforded, it is, I think, best in all cases to suggest to the patient or her friends a pelvic examination, which should be made under an anes thetic in the case of an unmarried woman, with permission to perform any minor operative procedure indicated as advisable by the examination.
In the case of a married woman, a pelvic examination should precede any efforts at treatment. The operative treatment of the case will depend, of course, on the condition found.
1. There may be no pelvic lesion or abnormality discoverable. In this case the condition is probably a spasmodic dysmenorrhcea, the pain being caused by cramp-like contractions of the uterine muscle, especially of that surrounding the internal os, and the appropriate treatment is to dilate the cervix up to 12 or preferably 14 f-legar, so as to overstretch the muscular fibres of the internal os and so obviate their abnormal contraction. After dilatation it is well to curette the uterus, as there may be an abnormal sensitiveness of the endometrium which will be relieved by curetting (see Endometritis). Permanent relief is more likely to be gained if the cervical canal, after dilatation and curetting, is packed for 4S hours with a strip of iodoform or bismuth gauze, which seems to produce a " vital dilatation " comparable to the effect produced on urethral stricture by tying in a bougie or catheter. This is successful in from 4o to 5o per cent. of cases; in others it gives temporary relief, and should be repeated when the dysmenorrhoea returns; and in others it is without effect. It is most likely to be successful when the dysmenorrhoea is of extreme severity, but only lasts a few hours. In the most severe and intractable type of these cases, as well as of those belonging to the next section, the question of removing the ovaries will probably arise as a last resort from the pain. The practitioner should be very chary of giving his consent to this operation. Ire should be perfectly convinced not only of the exist ence of unbearable pain, but of the fact that the pain is having an injurious effect on the patient's general health. He should remember that castra tion has its own evils in the shape of a premature menopause, and the nervous disturbance that accompanies it, and he should not forget that the removal of painful ovaries is not always followed by the disappearance of pain referred to them. The more experience one gains in gynecological work, the more one becomes convinced that removal of both ovaries in a young woman is seldom or never justifiable. The same objections arc not present to the removal of the uterus, and although this measure necessarily condemns the patient to barrenness, that is the less to be deplored, as most subjects of intractable dysmenorrhoea are also sterile. Whether it xvill be as efficacious can only be proved by trial.