[Reprinted from the New York Journal of Gynecology and Obstetrics 
for April, 1894.] 
DYSMENORRHCEA.* 
By Howard A. Kelly, M. D., 
Professor of Obstetrics and Gynaecology in the Johns Hopkins University, Baltimore, Md. 
Names have often acted as serious obstacles to scientific advance- 
ment in all branches of medicine. Thus, in gynaecology the names 
“ pyosalpinx ” and ‘‘ hydrosalpinx ” have long retarded a thorough 
investigation of the natural history of these pathological processes in 
their earlier stages by conveying an impression which has become 
fixed by tacit assent, that the pus and the serum in the tubes is the 
disease itself and not merely a by-product of the disease found in its 
later stages. 
“ Dysmenorrhoea ” is likewise nothing more nor less than pelvic 
pain associated with the menstrual congestion and the menstrual flow 
and is a concomitant symptom of a wide variety of diseases of the 
uterus, tubes, and ovaries. I wish to emphasize and insist upon 
this fact at the very outset, convinced that if you will accept my 
views I will be instrumental in helping a large number of suffering 
women and in saving you from committing certain errors common to 
the medical practice of to-day. 
Dysmenorrhoea is, therefore, merely an awkward name for a 
symptom common to numerous diseases ; it should consequently 
never be entered in a history as the diagnosis. 
To give precision to my statements I have analyzed, with refer- 
ence to this symptom, four hundred cases in which I have opened 
the abdomen for pelvic diseases. I find that two hundred and 
eighty-nine of the four hundred, taken in series as they were oper- 
ated upon, suffered from dysmenorrhoea, while one hundred and 
eleven had no dysmenorrhoea. Out of the four hundred cases more 
than half (two hundred and fifty-five) had some form of obscure pel- 
vic affection, such as usually escapes the attention of the general 
practitioner ; in other words, this number of women had either pelveo- 
peritonitis with adherent ovaries and tubes, tubercular peritonitis, 
* Read before the New York State Medical Society, February 6, 1894. Howard A. Kelly, M. D. 
pyosalpinx, hydrosalpinx, tubo-ovarian abscess, salpingitis or hsema- 
toma of the ovary. 
Now out of these two hundred and fifty-five cases of minor 
pelvic disease there were one hundred and eighty in which dys- 
raenorrhoea existed, while it was absent in but seventy-five. In 
addition to these two hundred and fifty-five there were fifty-five 
cases of retroflexion in the series of four hundred, of which forty-four 
suffered from dysmenorrhoea. The majority of these cases applied 
for relief solely because of pelvic pains, which were aggravated at the 
menstrual period, and many of them had been treated for months 
and years for “dysmenorrhoea.” 
In addition to the cases of pelvic inflammatory disease, small ova- 
rian tumors and retroflexion, there is still another group of dysmenor- 
rhoeic women whose suffering is due to small myomata. I have 
repeatedly discovered these tumors by a minute rectal examination in 
young women who have been treated persistently for “dysmenor- 
rhoea.” 
Believe me, Gentlemen, I would not have taken this trip to Albany 
to make these brief remarks before you, did I not believe it to be of 
the utmost importance that you, and through you the profession at 
large, should realize that they are holding under treatment for “ dys- 
menorrhoea” to-day a large number of women who have small* tu- 
mors or pelvic inflammatory disease. 
Let me put the converse of the proposition ; where do all the 
large myomata seen in our clinics come from if not from the small 
ones which are at first unrecognized ? Put the question to any 
one of these women with a mass of big tumors filling the abdomen, 
and she will tell you of years of menstrual pains and treatment before 
a correct diagnosis was made. 
Address the same question to any of the old cases of pelvic 
inflammatory disease and you will learn of years of fruitless treat- 
ment before the true condition was suspected. 
There is another type of dysmenorrhoea, common to young girls in 
whom the menstrual habit is becoming established. This type is 
usually associated with a variety of dyscrasias, the most prominent of 
which is chlorosis and does not often persist beyond the twentieth 
year. 
There is, further, the class of the neurotic and hysterical women 
whose entire nervous system is at fault and in whom moderate pain 
is described as “ agony.” This type is particularly prone to be asso- 
ciated with defective development of the uterus and ovaries. Dysmenorrhoea. 
3 
Above every other consideration, and before I speak of the direct 
treatment, let me impress you with the utter immorality of the use of 
morphine in combating this symptom “ dysmenorrhoea.” Under but 
one set of conditions, and one only, is the use of morphine justi- 
fiable, that is, when the dysmenorrhoea has been demonstrated to be 
due to a gross pelvic lesion and the patient is under preparation for 
its removal by operation. 
Treatment. 
There is too a strange blindness preventing many doctors from 
recognizing the hysterical element in their female patients. I have as 
a consequence of this want of professional insight seen many poor 
creatures tattooed with the hypodermic needle and saddled with this 
accursed habit. Never give morphine for a' protracted disease 
marked with paroxysms of pain not tending toward a fatal issue. 
For the young girl attention to hygiene, regulation of her exercise 
and schooling and, above all, rest in bed are invaluable in the treat- 
ment. Mild sedatives, hot tea and a full hot hip-bath, with the ad- 
ministration of aloes combined with myrrh or asafoetida to empty the 
lower bowel, accentuate the pelvic congestion and so assist in bring- 
ing on the flow. 
I need not dwell here upon such well-recognized facts as the 
necessity of treating chlorosis, rheumatism and other associated 
ailments when they exist. Be wary, gentlemen, in beginning what is 
commonly called “local treatment” in young women ; it is rarely of 
value and once begun is apt to be kept up indefinitely. If, however, 
the dysmenorrhoea is persistent and excessive in the young girl, do 
not delay but insist upon a thorough examination under anaesthesia 
per rectum and abdomen; remembering the maxim of the ancients : 
“ Magnum esi crimenperrumpere virginis hymen.” 
Where serious pelvic disease exists you will treat this and so re- 
lieve the dysmenorrhoea. If the existing disease threatens life or is 
incompatible with fair health, and there is no prospect of relief by 
waiting, you will without hesitation act in the patient’s best interest 
by removing tubes, ovaries or uterus to effect a cure. In less aggra- 
vated conditions, your judgment will be tested in weighing the pros 
and cons relative to an operative procedure; where the tubes are 
sealed and ovaries are bound down, you will have less hesitation in 
interfering and anticipating the menopause. When dysmenorrhoea 
persists and no local lesion is discoverable a thorough dilatation of 
the os uteri is often of service. I would estimate the utility of this 4 
Howard A. Kelly, M. D. 
procedure about as follows ; Seventy per cent, are benefited for a 
time ; about forty per cent, are benefited permanently, and about ten 
per cent, are cured. 
The best results are obtained in cases which are distinctly spas- 
modic in character. 
As a last resort, it is right in rare instances where the patient is 
not neurotic, and occasionally in spite of this complication, to remove 
ovaries and tubes for painful menstruation, which is wrecking health, 
even though the pelvic organs are known to be absolutely free from 
disease. 
Finally in recapitulation, almost without exception all those cases 
of pelvic inflammatory diseases which will later fall into specialists’ 
hands are to-day under treatment by general practitioners for “ dys- 
menorrhoea.” 
A careful examination under anaesthesia per rectum and abdomen, 
if necessary drawing the uterus down with tractors at the same 
time, and making what I call a “ trimanual examination,” will reveal 
the cause of the dysmenorrhoea. 
This examination must not be undertaken in young women with- 
out due delay and general treatment, during which time the case will 
often right itself. 
In young unmarried woman who have never been examined, the 
bimanual examination should not be conducted per vaginam. 
The practitioner must not fail to recognize and classify separately 
the purely hysterical cases, in whom local treatment of any kind is 
positively injurious. He must, however, in this very group of cases 
be most wary, recollecting that hysterical women are as equally liable 
as other women to have pelvic inflammatory ailments. 
Dysmenorrhoea depending upon tumors and inflammatory troubles 
must be relieved by treating the disease and not the symptom. 
Morphine must never be employed in treating dysmenorrhoea. 
Dilatation and curetting benefit a large percentage of cases 
which are uncoinplicated by other diseases and even cure a small per- 
centage. 
Ablation of the appendages is proper in rare cases of extreme and 
persistent dysmenorrhoea as well as for some intractable cases of 
membranous dysmenorrhoea.