Canad. M. A. J. 1 Sept. 1946, vol. 55 J MACFARLANE: PELVIC PAIN 267

"pre-sacral nerve", a popular misnomer. The ovarian PELVIC PAIN* sympathetic nerve supply is independent, originating from the superior mesenteric and renal plexuses via By K. T. MacFaXlane, M.D. the ovarian vessels and the hilum of the ovary. The Fallopian tube derives its nerve supply for the most part from the hypogastric plexus with some fibres MontreaWl from the ovarian ganglia. It is now generally accepted that pain from the pAIN is the symptom that most commonly pelvic organs themselves is transmitted through af- brings the patient to the physician for advice. ferent sensory nerve fibres into the sympathetic chain. These viscero-sensory nerves are relatively small in It has been stated that about one-sixth of all number and size and the impulses from the organs female patients consult their physicians for ail- themselves are therefore vague and poorly localized. The parietal peritoneum, however, is much more ments concerned with pain in the pelvis.' In richly supplied and thus the most definitely diagnostic our experience on a gynaecological ward the type of pelvic pain comes from irritation of the parietal peritoneum over the affected organ. For incidence of pelvic pain as a complaint ap- example, the initial pain in tubal pregnancy may be proached 35%o of all admissions. The subject of a dull, poorly localized (though unilateral) nature, as it arises from the stretching of the visceral peri- of pelvic pain is, therefore, one of paramount toneum by distension. When the tube perforates or importance to the gynaecologist and of great leaks, the pain is sudden, sharp and clearly localized- interest to the general practitioner, the internist a peritoneal irritation. or the surgeon. It may be one of the most Pelvic pain has been variously classified by baffling of all pelvic symptoms, requiring a keen contributors to medical literature. A satis- insight and great experience in its proper factory classification is that offered by Mengert,2 interpretation. who divides pelvic pain into two main groups: To clarify the term "pelvic pain" one must (1) Intragenital, in which the pelvic lesions remember that it may arise from the lower responsible are readily recognizable. (2) Extra- abdomen, the pelvis or the back. It may vary genital, in which there are normal pelvic organs. from a vague feeling of weight or pressure to INTRAGENITAL PAIN. (1) THE UTERUS an acute prostrating seizure. It may be localized or diffuse, constant or remittent. It may be A prominent obstetrical teacher once aptly associated with certain physiological processes, named the uterus "the pelvic heart" because it menstruation, defsecation, labour, etc., or it may contracts and relaxes at intervals throughout be quite independent of these. It is my purpose the reproductive life of the individual. These to review certain diagnostic aspects of pelvic rhythmical contractions under certain circum- pain as seen from a clinical standpoint. stances may become accentuated and with the increase, pain may result. During menstruation, Anatomy.-Let us recall some of the salient facts in pregnancy, and labour, a physiological process the anatomy and physiology of pelvic pain. Passing downwards on the aorta from the level of the superior may and does become painful. This is the most mesenteric artery is a network of nerve fibres arranged fundamental and easily interpreted variety of in somewhat parallel bundles, known as the inter- mesenteric nerves or the abdominal aortic plexus of intragenital pelvic pain. Nature's mechanism the autonomic system. At the level of the inferior for the promotion of drainage from the uterus, mesenteric artery they bifurcate, one group going with the artery and the other becoming the superior hypo- when confronted with an intra-uterine foreign gastric plexus at the level of the aortic bifurcation. body, is pain-producing. The pedunculated sub- This hypogastric plexus is situated in front of the last lumbar vertebra and the promontory of the mucous fibroid, the polyp of the fundus, and sacrum, between the two iliac arteries (the inter-iliac the extrusion of the products of conception dur- trigone). It is joined by filaments from the lumbar ganglia and subdivides below at the level of the ing abortion all give rise to pelvic pain. Thus first sacral verteb)ra into two lateral plexuses, the right in the patient with bleeding and clotting at and left inferior hypogastric plexus. These in turn lead downward along the lateral pelvic wall and at menstruation, the symptom of pain results from the level of the third sacral vertebra pass forward over-accentuation of uterine contractions. This into the broad pelvic plexus (of Frankenhauser). This is composed of lesser plexuses, the rectal, utero- pain is a typically rhythmical, deep-seated, lower vaginal and vesical. The parasympathetic fibres from abdominal, mid-line pain, sometimes referred to the sacral 2-3-4 also join in the formation of the pelvic plexus and supply the bladder, the uterus, and the the lumbo-sacral region of the back. rectum. The normal cervix is a rather insensitive Clinically, the great majority of afferent pain fibres from the uterus seem to be contained in the organ, as evidenced by our free use of cauteriza- superior hypogastric plexus, often described as the tion of the cervix without anesthesia. Dilata- *From the Department of Gynecology, the Mon- tion or instrumental pressure, however, is very treal General Hospital. painful. Young3 has described a cervical syn- Read before the London Academy of Medicine, March 28, 1946. drome, found in parous women, in which the Canad. M. A. J. 268 MACFARLANE: PELVIC PAIN L Sept. 1946, vol. 55 main symptom is recurrent chronic pain in the riage the pain associated with the period had almost disappeared but more recently it had again become lower abdomen and occasionally in the lumbo- severe. The periods now lasted six to ten days, with sacral area of the back. Leucorrhoeal.discharge clots. or Pelvic examination showed a normal parous lower usually precedes coincides with the pain. tract. There was no birth trauma and no evident pro- Dyspareunia is common. The pain, a mid-line lapse. The cervix was clean, pointing down and for- wards, and freely mobile. The uterus was slightly en- visceral uterine pain, can be reproduced on larged, in keeping with her parity, lying in deep pelvic examination by digital pressure on the mid-position, replaceable, but it would re-assume its posterior displacement quickly. cervix. The cervix usually shows a laceration Because of the menorrhagia, the pain, and the with varying degrees of endocervicitis and cystic extreme degree of the sensation of weight experienced degeneration. Infection of the cervix is also a by the patient, hysterectomy was advised, with a pre- sumptive diagnosis of adenomyosis being made. At common source of the so-called posterior para- operation a large uterus, regular in outline, lying in metritis involving the utero-sacral ligaments, the posterior position with the typical shaggy appearance of adenomyosis, was removed, along with the cervix. the most annoying symptoms of which are low The left ovary was the site of several small areas of pelvic pain and backache. Constipation, if endometriosis which were cauterized. Sections of the uterus showed very marked adenomyosis uteri. chronic, also contributes to this particular type of pain which is easily elicited by palpation of Degeneration of fibromyomata. Another the ligaments which may be extremely tender. rather common type of pelvic distress arising Radical cauterization of these infected cervices from the uterus is that associated with degen- under anesthesia results in marked improvement erative changes in uterine leiomyomata. As we but it is well to remember that adequate drain- all recognize, uterine fibroids usually grow age of the uterus is essential and in the follow- silently and progressively, with few symptoms. up of such procedures care should be taken to They derive their nutrition from the adjacent ensure patency of the cervix. uterine musculature and hence may have, in Birth trauma.-Birth trauma, with resultant certain locations, a rather precarious existence. cystoccele, rectocoele and prolapse, is another In the uterus undergoing rapid changes in size, common cause for pelvic distress. In these cases as in pregnancy or post-partum involution, we the discomfort is often described as a feeling are frequently confronted with degeneration of of weight, or pelvic pressure, frequently more a fibroid. The pain is quick to develop and of noticeable in the lower back. The pain may be constant, gnawing character. At first it is poorly accentuated by long periods in the erect posture localized, but later, as oedema and early degen- and by heavy lifting. The mechanism is usually eration begins, well circumscribed. When attributed to a peritoneal pull or displacement, necrosis is advameed it again becomes painless, and to circulatory stasis due to narrowing of often leading to a false impression of recovery. the lumen of the pelvic blood vessels involved. The pain is associated with marked tenderness It is accentuated a few days before menstrua- over an enlarging tumour and usually some gen- tion when congestion is normally increased. eral evidence of peritonitis, the symptoms even Adenomyosis.-This symptom of discomfort suggesting bowel obstruction at times. described as a "weight in the pelvis" is also common in association with the uterus of adeno- 2. THE ADNEXA myosis. In these cases the severity of the com- Consideration of adnexal lesions causing plaint often seems out of all proportion to the pelvic pain necessitates inclusion of all those size of the uterus and its downward displace- pathological lesions found in the Fallopian tubes ment. Again, it is definitely increased at and most of the ovarian lesions as well. menstruation, but its onset is usually after the Ectopic pregnancy. The acute abdominal flow has been established rather than premen- crisis of ruptured tubal pregnancy is easily strual. With adenomyoss, menorrhagia is recognized as an urgent condition requiring frequently associated. operative interference. In its classical state the sudden, sharp pain, evidence of shock, fainting, CAE 1 etc., should make the diagnosis easy. The un- Mrs. J.P., aged 42? para ii, misc. 0. This patient was admitted complaning of profue and prolonged ruptured or "slow leaking"' type however, may menses since the birth of her youngest child, sixteen a enigma. a years before; occasional sharp pain in the suprapubic be diagnostic In recent review of area and a constant- feeling of heaviness and weight cases over a 10 year period at the Montreal in the pelvis which had recently become unbearable. General Hospital,4 pain was a predominating Menses began at the age of sixteen, a regular 23-day cycle lasting 3 to 4 days with some pain. After mar- symptom in almost 100%0 of cases, regardless of Canad. M. A. J. 1 269 Sept. 1946, vol. 55 MACFARLANE: PELVIC PAIN type. It varied in intensity, but in almost every timing not recognized, needless laparotomy and case it, was the symptom which brought the oophorectomy may result. The sudden onset of patient to the physician. Amenorrhoea, dark acute pain, with a slightly elevated pulse and a chocolate-coloured vaginal discharge, a palpable disproportionately low temperature, strongly tender unilateral pelvic mass, often of indefinite suggests the diagnosis in the mild case. If the outline, with pain, supports a diagnosis of haemorrhage is severe, the symptoms of shock ectopic pregnancy.\ and intra-abdominal bleeding are obvious indica- Corpus luteum cyst.-A condition frequently tions for operative intervention. Conservation confused with extra-uterine pregnancy is that of of the ovary should be practised if at all possible, a persistent corpus luteal cyst of the ovary. As as recurrences of the severe type are extremely originally pointed out by Halban,5 there is a rare. great clinical similarity between the two condi- Pelvic inflammations.-Inflammatory lesions tions, a short period of amenorrhoea, unilateral of the pelvic organs causing pain include in- pain, vaginal spotting, and a palpable unilateral flammations of the uterus, tubes and ovaries, as pelvic mass. The laboratory findings are often well as the inflammations of the supporting similar. The early pain in this condition is pelvic fascia and ligaments, pelvic parametritis very similar to a tubal distension pain except and cellulitis. These lesions may be roughly that it is less localized, being ovarian in origin. divided into those of gonorrheeal origin, those With perforation or acute rupture of the corpus following sepsis in the post-partum or post- luteal cyst, especially if the intra-abdominal abortal periods, and those of tuberculous origin. haemorrhage is massive, the clinical picture is The pain of acute gonorrheeal pelvic inflam- identical. mation is the result of stretching of the visceral

Grafivan follicle. - Ruptured Graffian follicle, peritoneum plus that of the local peritonitis in with its acute pain, is another variation of pelvic the parietal areas. There is a constant throbbing discomfort which grows in importance as it is character to the discomfort, with superimposed more frequently observed. Pain, coincident with acute stabbing pains. It is almost always bi- ovulation or "Mittelschmerz" has as its chief lateral. Pain in these cases is not of as great characteristic, a regular periodicity. It is inter- diagnostic help as the general appearance of the menstrual and occurs a definite number of days patient in relation to her signs and symptoms. before the ensuing menstrual period. Some The patient is never as prostrated as her fever, women can predict exactly the onset of their leucocyte count, pain and tenderness would lead next menstruation by the regularity of this one to suppose. intermenstrual pain. It is located in the supra- The septic abortion or the post-partum case pubic region, usually diffuse throughout the with parametritis is much more gravely affected, pelvis, resembling a very mild labour pain, but with a rapid pulse, high fever, marked prostra- often unilateral and referred to one or other tion and the general appearance of one seriously iliac fossa. It may even alternate from one to ill. More frequently the pain in these cases is the other side in alternate months. It is usually referred to the back and to the perineum as well seen in the early years of sexual maturity al- as the lower abdomen. though it may continue to occur through the Endometriosis.-One of the most incapacitat- reproductive life of the woman. It is often ing of chronic-pelvic pains is that seen in con- associated with slight vaginal bleeding and by junction with endometriosis. Regardless of its means of vaginal washings microscopic blood exact etiology and pathological nature, it remains can be demonstrated in almost all cases." It as one of the most destructive painful lesions of may vary from a mild, transitory, annoying dis- non-malignant character found in the pelvis. comfort to a very severe recurrent pain which Pelvic pain usually associated with the men- leaves soreness for several days and as such may strual periods is the most important single symp- be very incapacitating. It is occasionally associ- tom.7 Acquired dysmenorrheea which develops ated with severe intra-abdominal bleeding and slowly and progressively, often becoming pro- shock,. simulating ectopic pregnancy or acute longed into the intermenstrual period, is very appendicitis. Even in its mild form it is fre- suggestive. Frequently this acquired menstrual quently misleading to the surgeon, especially discomfort is referred to the rectum, in those when right-sided. All too often, if the history cases of recto-vaginal and cul-de-sac involvement. is not carefully evaluated and the intermenstrual Sterility, dyspareunia,. adherent slightly en- PAIN [Canad. M. A. J. 270 MAcFARLANE: PELVIC L Sept. 1946, vol 55 larged cystic ovaries, tender nodules behind the practice but more recently less and less interest cervix or in the recto-vaginal septum with an is aroused by the condition. Since the recogni- adherent retro-displaced uterus, all support the tion that 30 to 40% of all uteri normally lie diagnosis. in the posterior position and never give symp- CASE 2 toms (the so-called "congenital retroposition"), we that tile positioin oI ttle uterus Miss J.S., aged 27, para 0, was admitted complain- have realized ing of pain of five days ' duration in the right lower cannot be of such importance as was once abdomen. This was of a continuous pulling character and had begun immediately following the last normal considered. Even acquired retroversion, when period. There had been increasing discomfort on de- not complicated by fixation or associated pro- fecation for the past two weeks, but there had been lapse, rarely gives symptoms. no other symptoms of bladder or intestinal character. She had been seen by two gynaecologists when first Persistent pelvic pain with an acquired affected and their presumptive diagnosis had been retroversion and no other abnormality, how- either pelvic inflammation, or acute appendicitis for which they had given her 300,000 units of penicillin ever, is suggestive of pelvic varices. The pa- with no improvement. There was no history of amenor- is usually the thin, aesthetic type of rhoea or other menstrual abnormality but on close tient questioning she stated that pain with the menses had woman, who has borne one child at least. The been gradually increasing over the past two years. She condition seems to bear little relation to fer- also stated that for some years she had experienced a sharp stabbing pain in the rectum at times. ' tility as these patients will frequently become She had had one previous attack of somewhat similar pregnant while under observation, ruling out pain two months before, while menstruating, but on this occasion it had been a general abdominal one with- any inflammatory basis for the pain. Although any and had subsided after three days. out localization pregnancy temporarily improves the condition, On admission, the temperature was 98.8, the pulse rate 68, and the respirations 20. General examination repeated pregnancies increase the symptoms. which showed was negative except for the abdomen, The pain is of a constant, growling character, tenderness on deep pressure in the right lower quadrant, with splinting and pain referred to the hypogastrium. somewhat increased in the pre-menstrual days On pelvic examination the outlet was marital and clean. exercise. Partial relief is usual when Cervix pointed down and slightly to the right and and by forwards. The uterus was normal in size, in mid- the patient is put to bed in the dorsal decubitus. some Filling the position, mobile but with tenderness. Constipationi is a usual accoinipanilmeuIt anld true pelvis and pushing the uterus forward was a tender cystic mass which encroached on the rectum dyspareunia may be present. Although the behind and seemed to extend into both adnexal areas. retroposition may be easily corrected, pessary Tenderness was mainly referred to the right side and was very marked. support is extremely difficult to maintain be- Leucocyte count was 10,950. Sedimentation rate was cause of the general softness and laxity of the normal and urinalysis was negative. In the absence of lower tract infection and general pelvic tissues. The pain does not respond to systemic reaction, and with the mobility of the uterus, pelvic heat or other physical therapeutic meas- the mass which closely resembled a pelvic abscess was diagnosed as a chocolate cyst of the ovary with recent ures; in fact it is often increased. hwamorrhage. Pelvic, varices are occasionally seen in cases Laparotomy was performed and a large, multilocu- lated, chocolate cyst of the right ovary, of endometrial in which the uterus is in normal position, and origin, was removed. Diagnosis was confirmed by the cases are due to obstructive pathologist. in these usually adhesions at the pelvic brim or congenital EXTRA-GENITAL PAIN "bands " from the mesentery of the distal the colon at its Extra-genital causes of pelvic pain are a portion of descending junietion source of great confusion and as I will later with the sigmoid. point out may well lead to pelvic neurosis and CASE 3 anxiety states if our efforts at diagnosis are Mrs. D.R.S., aged 25, para ii. This patient was seen not thorough and careful. with her first pregnancy in June, 1941, and after an Pelvic varices.-The first of these conditions uneventful pre-natal course was delivered of a 9 lb. baby after a 30 hour labour. On post-natal examina- which I should like to discuss is that of broad tion the uterus was retroposed but freely mobile. It ligainent varicosities. It is included in the was replaced, a ring pessary inserted and appropriate exercises given. After one normal period she became extra-genital group because it is most unusual pregnant for the second time, a 91/2 lb. baby being to palpate any abnormality in the pelvis except born exactly one year after the first child. Following the second delivery she was not seen again for 8 months, a mobile retroversion of the uterus. It is in- when she returned complaining of lower abdominal deed seldom that any thickening or palpable pains, increased by walking and bending, constipation, and dyspareunia. Examination revealed a large retro- mass is present in the adnexal area. Retro- verted uterus, easily replaceable, with bilateral adnexal position of the uterus at one time was con- tenderness but no palpable thickening. Pessary support was ineffectual. Vaginal diathermy was given on the sidered a major problem in gynaecological supposition that the tenderness was probably of inflam- Canad. M. A. J. 1 Sept. 1946, vol. 55 J MAcFARLANE: PELVIC PAIN 271 matory origin. There was no improvement; in fact diverticulosis and its inflammatory phase diver- the symptom of pain was increased. woman of During the following year she was seen frequently ticulitis. Usually occurring in the for the same complaints of increasing pain and deep over 40 years it can be well confused with pelvic distress on intercourse. The pain was somewhat relieved by bed rest but resumption of her duties always pelvic inflammatory disease or with malignancy caused its recurrence. Eventually it became localized of the ovary. As inflammatory tubal lesions in the left side and was so distressing that she requested are so the finding of uni- some operative relief. In the presence of normal pelvic seldom unilateral, findings, except for the mobile retroversion, this was lateral tenderness or mass in this type of case undertaken with some reluctanee, as by that time we The pain is of a dull aching type were almost convinced that the complaint was of non- is important. organic origin. Exploratory laparotomy was performed and there is usually the history of bowel and at operation there was found a large retroverted flatu- uterus with very marked pelvic varices in both broad disturbances, increasing constipation, ligaments, being more marked on the left side where lence, tenesmus, and crampy colicky pains. the veins were very tortuous, approaching one centi- During an acute attack there are obstructive metre in diameter. The uterus was well suspended and no other procedure was done. She has been completely symptoms. The relation of the pain with free of symptoms since that time. gastro-intestinal symptoms in these cases is the

Pelvic joints.-Another major cause for extra- most suggestive fact in diagnosis. such genital pelvic pain is the relaxation or strain Backache.-Backache in women is of of the sacro-iliac joints and of the pelvic girdle. common occurrence, that one gynaecologist has During the course of normal pregnancy there aptly defined woman as "a constipated biped are variable degrees of lower abdominal and with a backache". For some obscure reason is low back pain. These discomforts are thought the laity commonly suppose that backache, or to be due in the most part to the normal relaxa- due to one of two things, kidney disease, tion of the pelvic girdle with the resultant pelvic disorders. It is true that referred pain increased mobility of the sacro-iliac joints and from certain pelvic lesions localizes in the a the symphysis pubis. Strain of the joiiits may lower lumbar or sacral areas, but in higher come from sudden trauma, often minimal in percentage of cases the backache probably degree, or it may develop from a chronic arises from lesions of the spine or its supports. postural abnormality. The modern automobile In addition there are frequently cases of dis- seat, with its unnatural posture, may often comfort in the anterior portion of the pelvis initiate strain of these joints. which arise from lesions of the spinal cord or sensory nerve roots. The extra- The symptoms from either strain or relaxa- the posterior causes of backache are many, arthritis tion are similar and may be variable and mis- genital leading. There is usually low back pain but of the spine, myositis of the back muscles, super-imposed and often overshadowing it. relaxation of the pelvic joints, coccydynia, poor there is pelvic and lower abdominal pain. This posture, disturbances of feet, congenital ab- about the lumbo-sacral area and may be diffuse or localized and when the latter, normalities others. one must remember the the area of localization is a point about 11/4 many Again inches lateral and 2 inches below the umbilicus. cases of nervous exhaustion and fatigue; fre- discomfort. At times the only pain is referred to the rectum quently the back is the site of the and tip of the spine. Referred pain along It is imperative that a careful physical exam- be made in case in which the either the sciatic or femoral nerves is common. ination every With the characteristic discomfort experienced backache is of such a severity as to cause the to In well over 50% it is on sitting down or rising from a chair there patient complain. rather than a one. goes the inability to sleep comfortably in the an orthopaedic gynacological dorsal decubitus, preference usually being CASE 4 given to the prone or lateral positions. It is Mrs. J.M., aged 37, para 0. This patient was ad- usually possible to elicit an area of tenderness mitted from another hospital where she had been under treatment for 3 weeks previously for what she termed on deep pressure over the sacro-iliac joints. " sciatical" and an ovarian cyst. It was the second the X-ray examination is usually of little help un- attack of "sciatica" which she had experienced in past 7 months. As she was a graduate nurse her history less increased mobility of the joints can be was most accurate but somewhat tinged by a professional demonstrated by postural-changes. diagnostic license. The complaints on admission were pain in the right Diverticulosis.-No discussion of pelvic pain lower quadrant of the abdomen, pain in the right costo- of that vertebral angle and pain in the right hip and leg, would be complete without the inclusion radiating down the anterior surface of the thigh to the condition found in the large bowel known as knee. This pain was of a deeply situated constant type ECanad. M. A. J. 272 MACFANE: PELVIC PAIN L Sept. 1946. vol. 55 0 with a superimposed sharply acute spasm occurring at As has been pointed out, the orthoptedist irregular intervals. She had been examined by a gynec- ologist 7 months before during a period of menstrual probably shares with the gynaecologist the irregularity and he had reported a small ovarian cyst major responsibility. After complete investiga- on the right side. The past history was interesting for its length and tion, and trials of medical, endocrine, psycho- multiplicity of ailments. It began at the age of six, logical and physical treatments have proved with an appendectomy in 1915, a tonsillectomy in 1918, erythema iiodosum in 1928, cholecystitis in 1932. A futile, and in the presence of normal pelvic Neisserian infection was contracted in 1932. In 1943, findings, we still have a small group of cases she had a laparotomy for an ovarian cyst on the left side. The left ureter was seriously damaged at this of intractable pain. For these cases, symp- time, resulting in what she described as "sloughing" tomatic relief may be effected by the operation of the ureter. Six months later she had had the left kidney removed as it was completely non-functional. of "pre-sacral sympathectomy". Probably, She had then been well until the first attack of so-called because of a lack of knowledge, certain forms sciatica which was located in the left leg. Present general examination was negative except for of surgical treatment are for symptomatic the local condition. Pulse, temperature and respira- relief only; that is, we do not treat the cause; tions were normal. Abdominally there was increased resistance in the right lower quadrant and right flank often we do not know it. This operation should but no tenderness. Pelvic examination showed a clean be considered as such and used with discretion mnarital outlet. The uterus was in anterior position, normal in size, and freely mobile without pain. There after careful selection of cases. We feel that was some indefinite thickening behind and to the right the great majority of these cases of intractable of the uterus but no masses or cyst were palpable. Examination of the back showed moderate tenderness pain are of uterine origin and therefore the of the right sacro-iliac joint and just above that area, procedure should prove ideal. It consists of with radiation into the right lower quadrant and right thigh anteriorly. the removal of the superior hypogastric plexus X-ray showed a defect in the laminae of the fifth by transperitoneal approach and the cleaning lumbar vertebra, causing a forward slipping of that nerve vertebra on the first sacral segment with marked nar- out of all the fibres in the inter-iliac rowing of the intervertebral spacing between. There triangle. It can be done alone or as an added was slight posterior wedging of the body of the fifth lumbar vertebra and thinning of the intervertebral disc procedure to other minor surgical procedures with associated lipping and sclerosis of the adjacent in the pelvis. It is sometimes indicated in articular margins of the sacrum and fifth lumbar vertebra. those cases which show minor abnormalities A diagnosis of spondylolisthesis with osteo-arthritis not in keeping with the severity of the pain was made. of which the patient complains. TREATMENT On the gyntecological service of the Montreal General we have had a series of 35 Accurate diagnosis is the basis of all intel- Hospital cases over five and our ligent treatment. The pain of intra-genital the past years results have been uniformly excellent. We have made origin in a large number of cases falls into a an effort to select our cases carefully and use surgical group and in these cases cure or the operation only after other methods of partial relief should be effected in about 80%o control have failed. of cases. Physiotherapy or medical treatment for the non-surgical intra-genital lesions effects COMMENT a cure in about 60%o of cases. Occasionally the In adequately assessing any pelvic pain one complications of surgical treatment may be should first remember that it is a rarity to have almost as incapacitating as the primary disease persistent pelvic pain in the absence of some but improvement of technique and operative pathological lesion. A careful study of the training should do much to reduce these to a patient's nervous make-up, as well as an minimum. Surgical treatment of some cases assessment of her normal "pain threshold", is of birth trauma will be disappointing in its frequently imperative in order to ferret out effectiveness, due to faults in diagnosis, choice the true cause of pain. The highly emotional of procedure, or in inherent healing qualities. sensitive individual will be prone to exaggerate There is no satisfactory operative procedure the degree of discomfort and will therefore be for all cases of birth trauma; they must be troubled by pain of much less severity. This individualized. type of person, who is usually too energetic, The pain of extra-genital lesions requires expends her energies to a point of complete even greater care in diagnosis and as such fatigue, which in itself enhances the onset of often requires the combined efforts and co- pain. On the other hand, the stolid, phlegmatic operation of urologist, orthoptedist, and gynwe-. type of woman is not easily disturbed and so cologist before treatment may be instituted. spares herself much of the suffering which her Canad. M A. J. 1BAIRD: 273 Sept. 1946, vol. 55J DIARRIEA more fragile sister cannot escape. It is indeed RtSUMt unusual not to find some physical cause for Symposium our la douleur pelvienne. Celle-ci eat g0nitale ou extra-g6uitale. Les douleurs genitales sont pain in a woman with a stable nervous system. caua6es par lea d6srdres de l'ut4rus tels que le trau- There has been handed down through genera- matisme occwaionn6 par 1 'accouchement, les adenomy8mes et toutes lesions neoplasiques, par les maladies an- tions the false idea that all pain between the nexielles de tous ordres et par } 'endom6trioae. Lea umbilieus and the perineum of women originates douleurs extra-g6nitales sont dfies aux varices pelvien- nes, aux arthropathies de voisinage et aux maladies in the generative organs, especially if this pain abdominales. is exaggerated at the menses. For this I feel Dans chaque cas, la sympt6matologie et le diagnostic sont discut6s. Le traitement est envisag6 dans sea don- that the medical profession is largely to blame, n6es g4n6rales et une discussion sur la signification de as it is such an easy thing to say to a woman la douleur termine 1'article. JEAN SAUCIER demanding explanation or diagnosis as women usually do, "oh, you have a little cold in the ovaries ", or, "'your womb is tilted", or "'you have a small cyst there", in an eifort to explain CHRONIC OR RECURRENT DIARRH(EA* the etiology of some elusive pelvic pain, and this often in the absence of palpable pelvic BY Murray Baird, B.M.(Oxf.), M.R.C.P. (Lond.) abnormality. How often we are confronted by the woman whose only complaint is "a pain in Vancouver, B.C. my ovaries". Usually she has a very vague idea of her pelvic anatomy to say the least, and un- DIARRH(EA has been defined as "the too fortunately, her association of the discomfort frequent evacuation of too fluid stools". In with the pelvic organ usually has originated as a its acute form it is one of the commonest of result of the over-zealous efforts of some would- human ailments, especially in armies, and the be diagnostician in our own profession. Canadian Army was no exception. This paper It is better perhaps to postpone the diagnosis is not concerned with these acute attacks, but until further observation or investigation has with the very considerable number of patients, been made, or, in the absence of palpable pelvic both civilian and ex-service, who have con- abnormality, to shift one's diagnostic sights to tinuous or repeated trouble. The definition some other location and reassure the patient that immediately rules out those cases of rectal her pelvic organs are palpably normal. Many constipation or dyschezia which are really "psychological invalids" or "pelvic casualties" examples of retention with overflow. initiated by such poorly directed efforts, might CLASSIFICATION be saved years of mental distress by a more thorough consideration of their primary problem. Since we are dealing with a symptom of We should also avoid a complete shift in the many complex and diverse causes, it is essential other direction, labelling these patients as neu- to have some kind of working classification if rotics. Physical or mental stress may begin a we are to be intelligent in dealing with these neurosis but diagnostically the primary cause patients. Rylel in 1924 used an anatomical must be found and should not be confused with one, dividing the alimentary tract into its main the final state of the patient. parts, with the addition of two etiological causes, namely nervous factors and constitu- CONCLUSIONS tional disease. Bochus2 followed the same plan Pelvic pain is a prominent symptom in many in an expanded form in 1944, and Hardy and pelvic lesions. Its interpretation requires care- Watt3 have published a completely etiological ful investigation and correlation with other classification. Certainly in diagnosis it would symptoms and clinical findings. A careful study appear that we must localize the pathological of all systems is essential in diagnosis and process as far as possible, and also assess the treatment. importance of .various etiological factors. REFERENCES There are al- 1. MUSSEY, R. D.: Am. J. Obst. & Gyn., 37: 729, 1939. infection, infestation, nutrition, 2. MENGERT, W. F.: South. M. J., 36: 256, 1943. nervous or emotional causes 3. YOUNG, J.: Brit. M. J., 1: 105, 1938. lergy, neoplasm, 4. MACFARLANE, K. T. AND SPARLING, D. W.: Am. J. constitutional disease. Obst. & Gin., 51: 343, 1946. and 6. HALBAN, J.: Zentralbil. I. Gynak., 39: 409, 1915. 6. WHARTON, L. R. AND HENRIKSEN, E.: J. Am. M. Ass., * Read at the Seventy-seventh Annual Meeting of the 107: 1425, 1936. 7. COUNSELLER, V. S.: Am. J. Obst. & Gyn., 37: 788, Canadian Medical Association in General Session, Banif, 1939. Alberta, June 13, 1946.