A system of practical medicine. By American authors. Vol. 4

by Unknown

The seat of obstruction is almost always uterine, but may be in the vagina or at its entrance. There is much difference of opinion as to the relative frequency of occurrence of obstruction at the internal or external orifice of the cervix.

The pain in this form of dysmenorrhoea generally does not precede the flow. In character it is sometimes like colic, but its leading feature is expulsive effort. It occasionally so nearly resembles abortion as to require care to distinguish between them. It is frequently intermittent, presenting intervals of complete relief. In severity it varies widely. In some cases the patient assumes and maintains a certain position which she has learned affords her some relief. This indicates with great probability uterine distortion from fibroid tumor. The writer has met with a marked instance of this kind.

The flow is more irregular in this than in other forms. It is sometimes extruded drop by drop; more often it appears in gushes, the fluid accumulating and distending the uterus until expulsive efforts are excited. Clots are often thrown off under these circumstances in shape and size corresponding to the cavity of the uterus.

Absence of prodromata, presence of the fluid being necessary to excite the pain, the intermittent and especially the expulsive character of the pain, and the kind of clots, indicate the nature of the case. A certain diagnosis, however, rests alone on physical examination. This should be by the touch, bimanual and rectal, and the sound. Sometimes additional aid will be derived from the speculum. By touch the form, size, shape, and direction of the cervix are ascertained, and its relations to the body of the uterus. The sound will give evidence as to the patency and direction of the cervical canal and uterine cavity.

A diagnosis of obstructive dysmenorrhoea should not be rejected because the patient occasionally passes a period without pain. In the male an enlarged prostate may for a long time interfere but little with micturition, and then all at once completely obstruct the flow of urine. A diagnosis cannot be based alone upon the condition of the cervical canal as found during the intermenstrual period. Two elements are to be considered, each of which may, and doubtless often does, play a part: tumefaction from the congestion attendant on the process, and spasm. The latter, caused by reflex action excited by irritation in the body of the uterus, assumes a leading position with those who claim that obstruction is the sole cause of dysmenorrhoea. That it plays an active part in many cases cannot be doubted; that it is a necessary condition of even spasmodic dysmenorrhoea is disproved by the positive statement of Matthews Duncan, that in some cases he could pass a sound freely into the uterus during the paroxysms.

A due estimate of the part which a uterine flexion plays in producing the dysmenorrhoea is important, but very difficult. Theoretically, the narrowing of the canal at the point of flexion should account for the symptoms, but experience does not accord with theory. All cases of flexion are not accompanied by dysmenorrhoea, and when so accompanied removal of the deformity does not always cure. Siredey in 52 observations found only 22 cases of dysmenorrhoea. Emmet's carefully-prepared tables show that in nearly 50 per cent. of anteflexions menstruation is painless. The conditions necessary seem to be extreme flexion, producing an acute angle. In less-pronounced cases it is maintained by many that the flexion is an unimportant factor, and that the dysmenorrhoea depends upon secondary conditions produced by it, as endometritis and congestion. The problem is difficult, and each individual case requires careful study. The facts indicate that there is much in the pathology of this form of disease not yet fully understood.

Congestive dysmenorrhoea depends upon an advance of the menstrual congestion beyond the physiological limits. In these cases the patient generally suffers for a few days before the period from a sense of fulness, weight, and heat in the back and pelvic region. Pain follows, is more or less severe, and varies somewhat in character, although generally dull and heavy. The hypogastric region usually becomes distended, and is sometimes very tender to the touch over the ovaries, "especially on the left side, without any reason for the difference being known." After a longer or shorter duration of these symptoms the flow appears, and this is often, especially if free, followed by an amelioration of the pain. In many cases, however, there is no remission of the suffering upon the discharge occurring. Not infrequently the general circulation is affected, the face is flushed, the skin hot, and there is more or less fever.

The flow may vary widely as to quantity. It is often at first and for a time more profuse than normal. Leucorrhoea frequently precedes and follows it, persisting during the entire interval. During that time also the patient suffers much from backache and bearing down, with difficulty of walking or of remaining on her feet.

Upon examination the vagina is found hot and tumefied, and increased arterial action is evident to the touch. The uterus is tender, enlarged, and heavier than usual. In cases associated with or dependent upon chronic inflammation or areolar hyperplasia the increase of size of the uterus during menstruation is marked. The sound may be used to determine the amount of enlargement and also the amount of tenderness. In cases dependent on endometritis touching the interior of the organ causes severe pain. Dyspareunia is frequently a symptom in this class of cases.

The conditions upon which congestive dysmenorrhoea depends are various, and may be either general or local or both combined. Plethora is rare in females, and local congestions are much more frequently dependent upon anæmia, the abnormal condition of the blood favoring them directly and also indirectly by its effect on the nervous system. In past times gout and rheumatism were considered to act frequently as the cause of dysmenorrhoea. They have almost disappeared from view since the era of direct examination began. Malaria, however, as a possible cause or a powerful factor should never be overlooked in regions where it prevails. The sexual instinct plays an important rôle; enforced abstinence, especially when suddenly brought about, and excess, being alike effective etiological factors. Young widows and prostitutes are both subject to this form of disease.