Dysmenorrhea, from its Greek derivation, signifies a difficult monthly flow, and is applied to menstruation when that function becomes painful and difficult. Menstruation, like other healthy operations of the body, should be painless, but too frequently it is the case, that discomfort and distress commence twenty-four hours before the flow appears, and continue with increasing pain, sickness at the stomach, and vomiting, until the patient has to take to the bed. When the discharge does occur, speedy relief is sometimes obtained, and the patient suffers no more during that menstrual period. With others, the commencement of the function is painless, but from six to twenty-four hours after, the flow is arrested and the patient then experiences acute suffering. Pain may be felt in the back, loins, and down the thighs. Sometimes it is of a lancinating, neuralgic kind, at others, it is more like colic. Frequently the distress causes lassitude, fever, general uneasiness, and a sense of lethargy. There are those who suffer more or less during the entire period of the flow, while the distress of others terminates at the time when a membranous cast is expelled. For convenience of description, dysmenorrhea has been divided into the following varieties: neuralgic, congestive, inflammatory, membranous, and obstructive.

The neuralgic variety of dysmenorrhea, sometimes called spasmodic or idiopathic, occurs when there is excessive sensibility of the ovaries and uterine nerves, which sympathetically respond, especially to cutaneous, biliary, and sexual irritation, and when ovarian or uterine irritation is communicated to distant nerve-centres. In the first class, usually comprising lean persons of an encephalic temperament, whatever disorders the functions of the general system, instantaneously reflects upon the ovaries and uterine nerves, and the menstrual function Is correspondingly disturbed, and, instead of being painless, the flow becomes spasmodic, with paroxysms of distress. In the second class, which includes those persons who are plethoric, the ovarian and uterine nerves seem to be the origin and centre of irritation, which is sometimes so severe as to cause indescribable pain. We have known women who affirmed that the severity of labor pains was not so great as that from this cause. In one instance, the subject suffered thus for eleven years, and then became a mother, and has ever asserted that her periodic suffering was far more intense than the pain experienced during her confinement. These neuralgic pains fly along the tracks of nerves to different organs, and capriciously dart from point to point with marvelous celerity, producing nausea, headache, and sometimes delirium.

[pg 693]In the congestive variety of dysmenorrhea, the menstrual period may be ushered in without pain; after a few hours, the pulse becomes stronger and more rapid, the skin grows hot and dry, the menses stop, there is uneasiness, restlessness, and severe pelvic pains. Evidently, the mucous membranes of the Fallopian tubes and uterus have become congested, and the pain results from the arrest of the functional process, the exudation of blood.

The causes are plethora, exposure to cold, excitement of the emotions or passions, and a morbid condition of the blood. Sometimes congestion arises in consequence of a displacement of the uterus.

In the inflammatory variety, the mucous membrane of the uterus is the seat of irritation. The blood flows into the capillary vessels in greater abundance than is natural, and those vessels become over-dilated and enfeebled and so altered in their sensibility as to produce local excitement and pain. It may be associated with inflammation of the ovaries, peritoneum, or bladder. Upon the return of the menses, there is a dull, heavy, fixed pain in the pelvis, which continues until the period is completed. There is generally tenderness of the uterus, and also leucorrhea during the intervals between each monthly flow.

In the membranous variety of dysmenorrhea, the entire mucous membrane which lines the cavity of the uterus, in consequence of some morbid process, is gradually detached and expelled at the menstrual period.

Symptoms. There are steady pains at the commencement of the menstrual flow, and they increase in violence and become decidedly expulsive. The mouth of the uterus gradually dilates, and finally, the membrane is forced out of the uterus, attended with a slight flow of blood and an entire subsidence of the pain.

The treatment, in all the preceding varieties of dysmenorrhea, should consist of measures to determine the circulation of the blood to the surface, and increase the perspiratory functions. Congestion and inflammation of the internal organs are generally induced by exposure to cold or from insufficient clothing. Sometimes they follow from neglect of the skin, which is not kept clean and its excretory function encouraged by warm clothing. The domestic treatment at the monthly crisis should be commenced by the administration of hot foot, and sitz-baths, after which the patient should be warmly covered in bed, and bottles of hot water applied to the extremities, back, and thighs. Dr. Pierce's Compound Extract of Smart-weed should be given in full doses, frequently repeated, to secure its diaphoretic, emmenagogue, and anodyne effects, which, for this painful affection, is unsurpassed. For the radical cure of this disease, whether of a congestive, inflammatory, or neuralgic character, Dr. Pierce's Favorite Prescription, which is sold by druggists, is a pleasant and specific remedy, which will most speedily correct the abnormal condition that produces the trouble, and thereby obviate the necessity of passing this terrible [pg 694]ordeal at every monthly period. The patient should take two teaspoonfuls of the medicine three times a day, and keep up its use in these doses for weeks. Frequently, one month will suffice to cure, but in most cases, a longer season is required. In the end, the suffering patient will not be disappointed, but will become a new being, ready for the enjoyment and duties of life. The bowels should be kept regular throughout the treatment by the use of Dr. Pierce's Pleasant Pellets, if necessary. A hand or sponge-bath should be used daily to keep the skin active, and be followed by a brisk rubbing of the surface with a rough towel or flesh-brush. A wet sheet pack will cleanse the pores of the skin and invite the blood into the minute capillaries of the surface, and thus prove of great benefit. It should be repeated after an interval of seven days, but ought to be omitted if near the approach of a menstrual period. The clothing should be warm, to protect the system against changes of temperature; especially should every precaution be taken to keep the feet dry and warm. The patient should walk in the open air, and the distance should be regularly lengthened at each succeeding walk. If the course of treatment which we have suggested be faithfully pursued, a permanent cure will be effected.

In the obstructive variety of dysmenorrhea, some organic impediment hinders the exit of the menstrual blood from the uterus, which, consequently, becomes distended and painful. The pain may be constant, but is most acute when the uterus makes spasmodic efforts to discharge the menstrual blood. If these efforts prove successful, there is an interval of relief. Flexion or version of the womb may produce partial occlusion of the canal of the neck of the uterus, thus preventing the free flow of the menstrual fluid through it. Tumors located in the body or neck of the uterus often cause obstruction to the free discharge of the menses. Imperforate hymen and vaginal stricture also sometimes cause obstruction and give rise to painful menstruation. As these several abnormal conditions and diseases will be treated of elsewhere in this volume, we omit their further consideration here.

Partial adhesion of the walls of the neck of the womb may result from inflammation of the mucous lining, and prevent a free and easy exit of the menstrual fluid. In many cases, the contracted and narrowed condition of the canal of the cervix seems to be a congenital deformity, for we can trace it to no perceptible cause. It is also true that contraction and partial, or even complete, stricture of the cervix, or neck of the womb, often results from the improper application of strong caustics to this passage by incompetent and ignorant surgeons. Every person has observed the contraction of tissue caused by a severe burn, which often produces such a distortion of the injured part as to disfigure the body for life. A similar result is produced when the neck of the womb is burned with strong caustics. The tissues are destroyed, and, as the parts heal, the deeper-seated tissues firmly contract, forming a hard, unyielding cicatrix, thus constricting the [pg 695]neck of the womb, through which the menses pass into the vagina.

Illustration: Fig. 3. THE UTERINE DILATOR. This instrument is introduced into the canal of the uterine neck with its blades closed. By means of the thumb-screw the blades are then separated as shown in this illustration, the cervical canal being thereby dilated to the required extent.
Fig. 3. THE UTERINE DILATOR. This instrument is introduced into the canal of the uterine neck with its blades closed. By means of the thumb-screw the blades are then separated as shown in this illustration, the cervical canal being thereby dilated to the required extent.

Treatment. From the nature of this malady, it will readily be seen that no medical treatment can effect a radical cure. We must therefore resort to surgery. In a small proportion of cases, the stricture may be cured by repeated dilations of the constricted part of the cervical canal. This may be accomplished by using a very smooth probe which is fine at the point, but increases in size, so that its introduction will widen and expand the orifice and canal. The stricture may be overcome in many cases by using different sized probes. In some instances, we have employed the uterine dilator, represented by Fig. 3. We have also introduced sea-tangle and sponge tents into the neck of the womb, and allowed them to remain until they expanded by absorbing moisture from the surrounding tissues. The latter process is simple, and in many cases preferable. By means of a speculum (see Figs. 15 and 16), the mouth of the womb is brought into view, and the surgeon seizes a small tent with a pair of forceps and gently presses it into the neck of the womb, where it is left to expand and thus dilate the passage. If there seems to be a persistent disposition of the circular fibers of the cervix to contract, and thus close the canal, a surgical operation will be necessary to insure permanent relief. In performing this operation, we use a cutting instrument called the hysterotome (see Figs. 4 and 5). By the use of this instrument, the cervical canal is enlarged by an incision on either side. The operation is but slightly painful, and, in the hands of a competent surgeon, is perfectly safe. We have operated in a very large number of cases and have never known any alarming or dangerous symptoms to result. After the incision, a small roll of cotton, thoroughly saturated with glycerine, is applied to the incised parts, and a larger roll is introduced into the vagina. The second day after the operation, the cotton is removed, the edges of the wound separated by a uterine sound or probe, and a cotton tent introduced into the cervix, and allowed to remain, so that it will expand and thus open the wound to its full extent. This treatment must be thoroughly applied, and repeated every alternate day, until the incised parts are perfectly healed.

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Illustration: Fig. 4. WHITE'S HYSTEROTOME. In operating, this instrument is introduced into the canal of the neck of the womb, when a thumb screw in the end of the handle is turned, by which a small blade is thrown out from each side, and as the instrument is withdrawn from the canal an incision is made on each side, thus enlarging the passage. The upper figure illustrates the instrument closed, ready for introduction; the lower one, with the blades projected for cutting.
Fig. 4. WHITE'S HYSTEROTOME. In operating, this instrument is introduced into the canal of the neck of the womb, when a thumb screw in the end of the handle is turned, by which a small blade is thrown out from each side, and as the instrument is withdrawn from the canal an incision is made on each side, thus enlarging the passage. The upper figure illustrates the instrument closed, ready for introduction; the lower one, with the blades projected for cutting.

Many times patients cannot understand why it is that the operation of cutting the constricted cervix causes no pain; they often being entirely unconscious of the making of the incision. The explanation is easy. The cervix uteri, or neck of the womb, is supplied with but few nerves of sensation, and is almost as destitute of sensation as the finger or toe nails, the paring of which causes not the slightest pain. On this account we never find it necessary to administer chloroform or any other anÆsthetic when undertaking this operation. If the patient be extremely sensitive the application to the cervix of a weak solution of cocaine is quite sufficient to completely benumb or anesthetize the parts so as to entirely avoid all pain from the operation.

Illustration: Fig. 5. STOHLMAN'S HYSTEROTOME. This instrument has two cutting blades which shut past each other, as seen in the lower figure, so as not to cut when introduced into the canal of the uterine neck. After introduction, the cutting blades are separated, as shown in the upper figure, the extent of the incision being regulated by the thumb-screw attached to the handles, as represented in the lower figure.
Fig. 5. STOHLMAN'S HYSTEROTOME. This instrument has two cutting blades which shut past each other, as seen in the lower figure, so as not to cut when introduced into the canal of the uterine neck. After introduction, the cutting blades are separated, as shown in the upper figure, the extent of the incision being regulated by the thumb-screw attached to the handles, as represented in the lower figure.

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