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THE PREVALENCE OF COMMON MENSTRUAL SYMPTOMS
61 THE PREVALENCE OF
that the serum alkaline phosphatase in normal pregnancy varies from about 6 King-Armstrong units at thirty weeks up to a maximum of 12 units at forty-three weeks. In this case the alkaline phosphatase rose to 63 units, which is
unusually high even findings are similar to Ohlsson (1959).
acute
M.B.
in this syndrome. The X-ray those described by Svanborg and
be excluded-namely, drugand bileduct calculi. There is no induced jaundice evidence that chlorpromazine or other hepatotoxic drugs were taken by this patient at any stage in either pregnancy, and the final cholangiogram seems to exclude calculi. Neither the history nor the biochemical tests suggest any of the more severe types of jaundice met with in pregnancy-i.e., haemolytic jaundice, jaundice associated with hyperemesis or eclampsia, or obstetric Two other
COMMON MENSTRUAL SYMPTOMS
OF THE MEDICAL RESEARCH COUNCIL UNIT FOR RESEARCH ON THE
EPIDEMIOLOGY OF PSYCHIATRIC ILLNESS, DEPARTMENT OF PSYCHOLOGICAL MEDICINE, UNIVERSITY OF EDINBURGH
causes must
yellow atrophy.
"
Silver " stools are said to be passed in several disorders associated with a disturbance of fat metabolism
(MacNalty 1961). Ogilvie (1955, 1963) suggested that the silver " stool was diagnostic of carcinoma of the ampulla of Vater, and that it was produced by the combination of a clay-coloured stool and simultaneous slight bleeding high in the alimentary tract (Thomas’s sign). It does not seem to have been reported before in obstetric "
hepatosis.
In this case it was attributed to the administration of oral iron in association with the stool of obstructive jaundice. Such stools have since been reproduced by giving oral iron to jaundiced patients (Creamer 1963). Thorling believes that obstetric hepatosis is due to incomplete intrahepatic biliary obstruction precipitated by hepatic damage, whose cause remains obscure. Nixon et al. (1947) and Svanborg and Ohlsson (1959) by liver biopsy have demonstrated biliary thrombi in the canaliculi and mild degeneration. Nixon et al. in 1947 advised termination in "jaundice of pregnancy ", but since then the correct treatment has been shown to be conservative. Besides prematurity, there seems to be no danger to the baby, and there is no evidence that the liver is permanently damaged. My thanks are due to Mr. G. W. Garland and Dr. B. Creamer for permission to publish this case. REFERENCES
Barnes, C. G. (1962) Medical Disorders in Obstetric Practice; p. 113, Oxford. Comerford, J. B. (1962) J. Obstet. Gynœc. Brit. Cwlth. 69, 1022. Creamer, B. (1963) Personal communication. Friedberg, V. (1962) Geburts. u. Frauenheilk. 22, 109. McAllister, J. E., Waddell, J. M. (1962) Amer. J. Obstet. Gynec. 84, 62. MacNalty, A. S. (1961) The British Medical Dictionary. London. Nixon, W. C. W., Egeli, E. S., Laqueur, W., Yahya, O. (1947) J. Obstet. Gynœc. Brit. Emp. 54, 642. Ogilvie, H. (1955) Brit. med. J. i, 208. (1963) Personal communication. Samuels, B. (1961) Obstet. Gynec. 17, 103. Sheehan, H. L. (1961) Amer. J. Obstet. Gynec. 81, 427. Svanborg, A., Ohlsson, S. (1959) Amer. J. Med. 27, 40. Thorling, L. (1955) Acta. med. scand. 151, suppl. 302, 1. Vincent, C. R. (1957) Obstet. Gynec. 9, 595. Von Woert, M. H., Kirsner, J. B. (1961) Gastroenterology, 40, 633. —
"... I am sure that this policy of upgrading people’s skills and qualifications all through life is going to be one of the essentials of the age of automation ... We shall have to do much less in the way of stuffing youngsters at school or university or technical college with present-day knowledge, and much less in the way of equipping them for this or that job in lifefor the present-day knowledge may be useless in ten years and the job non-existent. We shall have to put the emphasis instead on learning how to continue learning, on training young minds in such a way that they are both able and eager to enter into new fields of knowledge and skill from time to time all through their lives as changing conditions require."-S. LILLEY, Nature, Lond. 1963, 198, 1137.
NEIL KESSEL Cantab., M.R.C.P., D.P.M.
ALEC COPPEN Brist., D.P.M.
M.D.
OF THE MEDICAL RESEARCH COUNCIL NEUROPSYCHIATRIC RESEARCH UNIT. CARSHALTON. SURREY
THE work measure the
reported here is the first part of a study to frequency of symptoms before and during menstruation, and to relate such symptoms to personality type. There have been many estimates of the prevalence of dysmenorrhoea, all of which have shown it to be common, especially among young girls. But these results have been based upon considerations of selected groups of the population such as schoolgirls (Golub et al. 1957), students (Schuck 1951), Service personnel (Drillien 1946), and factory workers (Bickers and Woods 1951). The prevalence of premenstrual symptoms has been measured
study, 30% of factory applied for treatment of these symptoms. Pennington (1957) suggested that 95% of American women suffered from premenstrual symptoms at one time only rarely.
In Bickers and Woods’
workers had
another. In all these inquiries the prevalence of symptoms has been determined either by interview or by questionnaire. The subjectivity of the symptoms makes them peculiarly liable to influence by the wording used to ascertain their existence. We thought, therefore, that a standard questionnaire would provide more consistent and reliable information than an interview. We could not share the view put forward by Davis (1938), in his monograph on dysmenorrhoea, that " it is advisable to discount statistics based upon questionnaires, depending as they do upon the patient’s own assessment of her disability ". Only the patient experiences her symptoms. Who else can be competent to assess them ? Of course, women vary in their descriptions of the character of menstrual pain and of its site, its timing, and its duration, and no single physiological or pathological process accounts for the complaint in every woman. Nevertheless, both in common parlance and in medical jargon, a global term is used to embrace all these items, and it is to cover this broad symptom of pain with the periods that we use the medical term for painful menstruation. We would emphasise that this inquiry deals only with symptoms, and that we have no objective evidence of the subjects’ behaviour. Reliable correlations between menstrual symptoms and personality required data from a representative sample of the population. Since symptoms are influenced by such factors as age, civil state, and parity it was necessary to use a normal population group. We were particularly anxious to avoid the serious pitfall of basing conclusions upon a study of patients. Not all women with menstrual symptoms complain to their general practitioners; few of those who do are referred to a gynaecologist, and fewer still to a psychiatrist. Important selective factors are at work, and these bias any group of patients that is studied. Some psychiatrists have even formed their theories from the examination of patients referred for a completely different condition. Reliable conclusions about the significance of psychological factors require, first, a knowledge of the or
62
prevalence of menstrual symptoms in a population sample; and, secondly, correlation of such symptoms with personality type. Method 500 women of menstrual age were chosen from different parts of England by a two-stage sampling method. Ten general practitioners known to one of us or obtained from the research register of the College of General Practitioners (none of them had expressed special interest in either gynaecology or psychiatry) were approached, and from the lists of each a random sample of 50 women between the ages of eighteen and fortyfive was drawn. The first sampling stage was not random; if the selection of doctors introduced a bias, randomising the second stage could not eliminate this. Checks were, therefore, built into the design so that atypical results from any practice would be discovered. After a pilot study based on 50 subjects, a definitive questionnaire was drawn up concerning common menstrual symptoms. TABLE I-THE PRACTICES AND THE SAMPLE
This, together with the Maudsley Personality Inventory, was to each subject with a covering letter outlining the As command of English is purpose of the investigation. necessary to complete the personality inventory we excluded any woman whose name clearly indicated that English was not her first language. During the survey 76 subjects were replaced by others from the same doctor’s list, if we learned that they had moved away, or in some instances because they told us that they were no longer menstruating. Otherwise, no subjects were replaced. If no reply had been received, follow-up letters were sent at intervals of one, two, and four weeks after the original inquiry. The distribution of the practices, and the response to the questionnaire are shown in table I. 54% of the sample responded to the initial approach, 80% after one reminder, and 89% after two. The third reminder raised the response-rate to the very satisfactory level of 93%.
posted
TABLE III-PREVALENCE AND SEVERITY OF MENSTRUAL SYMPTOMS
Subjects were asked to select which of these words best described how they felt: 54% said depressed, 30% tense, 10% nervous, and 6% anxious. t 80% of those reporting swelling mentioned " stomach or abdomen", 54% mentioned breasts, 9% mentioned feet or ankles.
*
were
asked their age, their civil state, their
parity,
and whether
they were menstruating at the time of completing the form. Except for these last personal questions all other responses were made by putting a cross in an appropriate box. We have considered significant only those results which are beyond the 1 % level of probability. Results * The age, civil state, and parity of the sample are shown in table II. There is a small deficit of women aged eighteen to nineteen and aged forty-five, but otherwise the sample is unremarkable. 22 % of the women were menstruating at the time of completing the form, which is slightly but not significantly more than would be expected on the basis of a five-day flow and a twenty-eight day cycle. We later learned that some women had kept the questionnaire until their next period before completing it. Those menstruating when they filled in the form did not differ from the rest in frequency or severity of menstrual symptoms. 82% of the women had regular periods. 3% were unsure if they were regular or not, and 16% were so irregular that they did not know when the next period would come. The prevalence of the various symptoms is shown in table iii, and the time when they were worst in the figure. Correlations that were found between symptoms are shown in table IV. TABLE IV-SIGNIFICANT CORRELATIONS BETWEEN MENSTRUAL SYMPTOMS
The Questionnaire Questions were asked about pain, irritability, depression, anxiety, nervousness or tension, and headaches. Subjects were asked to rate these on a four-point scale-nil, slight, moderate, and severe. They were also asked about swelling of the body, and they had simply to indicate whether this occurred and in what site. For each of these symptoms they were asked the time in relation to the periods when it was worst, and also whether they suffered from the symptom between periods. Other questions concerned regularity of the menses and reduction in normal daily activity during them. Respondents TABLE
II-AGE, CIVIL STATE, AND PARITY
OF
SUBJECTS
P<0’01 for all figures given. N.s. =not Rank correlation coefficient T.
significant.
These tables and the figure should be consulted when the results for individual symptoms are described in turn. Late responders exhibited the same prevalence figures as those who needed no reminding.
Dysmenorrhaea Dysmenorrhoea
was
experienced
to a severe
degree by 12%,
moderate or severe degree by 45% of all subjects. It was maximal on the day the period started. Its prevalence was unaffected by marriage, but it declined with parity; severe period pain was experienced only half as often after the birth of the first child, and moderate symptoms were reduced after the second (table v). This negative association of pain and parity is
and
to a
we present only those results which relate to the prevalence of symptoms and the characteristics of the population. Results
here
concerning personality 1963).
and Kessel
are
being published separately (Coppen
63
statistically significant. There is a similar negative correlation between pain and age; however, using partial rank-correlation coefficients, we have been able to show that the decline in dysmenorrhcea with parity remains statistically significant even when the effect of age is controlled. Dysmenorrhoea is the most important of all menstrual symptoms in causing reduction of everyday activity. Dysmenorrhoea is significantly correlated with menstrual irrita-
Reduction in Activity Each subject was asked to assess the effect of her periods on her everyday life. 21% of women reduced their activities, but only 7% were appreciably affected by their menstrual period. 1 woman in 36 spent some extra time in bed.
bility, depression, headaches, It is sensations of swelling, &c. unrelated to regularity of the periods. Psychological Symptoms Each subject was questioned about menstrual irritability, and whether she became depressed,
The prevalence of menstrual symptoms is very high. More than 1 woman in 9 reported severe degrees of pain, of irritability, or of headache in association with her periods; and 1 woman in 16 reported that she gets very depressed or tense. 4 out of 5 women are conscious of swelling of the body, 1 in 14 restricts her activities during menstruation, and 1 in 7 has irregular periods. Clearly only a fraction of these people bring their symptoms to the doctor, and few of those who do are referred to the gynxcologist or the psychiatrist. Certain symptoms-irritability, depression and tension, headache and body swelling-cluster in a temporal relationship. They are all maximal one or more days before the period begins, and they are significantly intercorrelated, so that a woman who experiences one is likely to experience the others. They form a syndrome conforming closely to that described by Frank (1931), by Rees (1953a and b), and by Greene and Dalton (1953). Epidemiological support is thus given to clinical observation. In fact, the syndrome is far more widespread than has been believed hitherto, moderate or severe degrees of it occurring in about a quarter of all women. The high prevalence of reported sensations of swelling in the breasts and abdomen premenstrually is not readily explicable in the light of the finding by Bruce and Russell (1962) that water retention did not regularly occur in the premenstruum. It is possible that the sensation of swelling is related to a redistribution of water and electrolytes between intracellular and extracellular compartments of the body. Such a redistribution is found in cases of severe depression (Coppen and Shaw 1963), and perhaps the study of physiological changes in depression and menstruation may show common factors which are related to the regulation of mood. Dysmenorrhoea is significantly correlated with the premenstrual syndrome; but here an interesting feature emerges. We compared the timing of dysmenorrhoea in women who complained of the premenstrual syndrome with that in women without this symptom. Of those with the premenstrual syndrome and dysmenorrhcea this symptom developed before rather than during the period in 40%, compared with only 22% of the rest of the subjects with dyamenorrhoea in whom it developed before the period. This difference is significant. It seems, therefore, that one sort of period pain occurs premenstrually and can be regarded as an uncommon feature of the premenstrual syndrome, while the more usual type is worst during the period and is not part of the syndrome.
Differences between
Practices The differences between the various practices in the prevalence of menstrual disorders were not important. Menstrual irritability was significantly low in the Bloomsbury practice, but only 30% of the subjects there were married. This is because a high proportion were university students. Subjects who were registered with women doctors had not any increased prevalence of menstrual symptoms. Discussion
anxious, nervous, or tense around the time of her period; and she was asked to select which of these words best described how she felt at the time. In addition to irritability, most women who
experienced psychological symptoms selected depression and tension as the best descriptive words. worst
They
These symptoms are before the period starts. are significantly correlated
The time, relative to menstruation, when the various symptoms were said to be at their worst.
with headaches, swelling, and reduction in activity during menstruation; but they are correlated with parity, nor with age. Irritability, however, significantly increased by marriage (table v).
Menstrual Headaches Menstrual headaches, although they showed
a
slight
not was
pre-
ponderance before the period began, were more evenly distributed before and during the period. The table of correlations shows an association between dysmenorrhcea and other menstrual symptoms, and also that headaches played a part in reducing normal activity during the periods. In contrast to dysmenorrhoea, headaches are positively correlated with age and parity.
Swelling Subjects
were asked if they had any swelling of the body round about the time of their periods, and if so to state where it occurred. No less than 72% reported some swelling; of those who did 4/5 cited the breasts and 1/2 mentioned the abdomen; only 1/10 indicated feet or ankles; and negligible numbers mentioned the face, neck, fingers, or hands. The symptom was much worse premenstrually. Swelling was correlated with most of the other menstrual symptoms, and with reduction of everyday activity during the periods. TABLE V-EFFECT OF MARRIAGE AND OF PARITY ON DYSMENORRHCEA AND THE PREMENSTRUAL SYNDROME
Summary The prevalence of symptoms associated with menstruation has been measured in a population sample of 500. In all cases it was high.
64
Pain
was worst on
the first
symptoms which tended
day of the period. The other
in the same women were worse premenstrually. Thus there are two very common but distinct entities-the premenstrual syndrome and to occur
dysmenorrhoea. We should like to express our thanks to the general practitioners who assisted us in this research: Dr. R. F. Fairweather, Dr. H. C. Faulkner, Dr. D. M. Grant, Dr. C. F. Hingston, Dr. B. Kessel, Dr. Kathleen Lane, Dr. I. G. McGregor, Dr. Betty Margetts, Dr. J. M. Rea, Dr. A. Ryle, and Dr. J. L. Skene. We are most grateful to Mr. P. M. Payne, director of the South Metropolitan cancer registry, for his assistance and advice in the statistical analysis of the data. REFERENCES
Bickers, W., Woods, M. (1951) Texas Rep. Biol. Med. 9, 406. Bruce, J., Russell, G. F. M. (1962) Lancet, ii, 267. Coppen, A. J., Kessel, N. (1963) Brit. J. Psychiat. (in the press). Shaw, D. (1963) To be published. Davis, A. A. (1938) Dysmenorrhoea. London. Drillien, C. M. (1946) J. Obstet. Gynœc. Brit. Emp. 53, 228. Frank, R. T. (1931) Arch. Neurol. Psychiat., Chicago, 26, 1053. Golub, L. J., Lang, W. R., Menduke, H., Gordon, H. C. (1957) Ame J. Obstet. Gynec. 74, 591. Greene, R., Dalton, K. (1953) Brit. med. J. i, 1006. Pennington, V. M. (1957) J. Amer. med. Ass. 164, 638. Rees, L. (1953a) J. ment. Sci. 99, 62. (1953b) Brit. med. J. i, 1014. Schuck, F. (1951) Amer. J. Obstet. Gynec. 62, 559. —
—
EARLY POSTOPERATIVE GASTROINTESTINAL ACTIVITY N. G. ROTHNIE Lond., F.R.C.S.
M.S.
SENIOR REGISTRAR
R. A. KEMP HARPER M.D. Edin., F.R.C.P.E., F.F.R. DIRECTOR, DIAGNOSTIC X-RAY DEPARTMENT
B. N. CATCHPOLE Manc., F.R.C.S.
M.D. ASSISTANT
ST.
DIRECTOR, SURGICAL UNIT
BARTHOLOMEW’S HOSPITAL, LONDON, E.C.1
STANDARD surgical teaching today is that the alimentary result of reflex inhibition invariably becomes inactive after major abdominal surgery (Aird 1957, Cokkinis 1957, Le Quesne 1957, Jamieson and Kay 1959, Maingot 1961, Farquharson 1962). The period of inactivity, or postoperative ileus, is thought to last for up to three days, according to the operation, during which time the patient is tided over by gastric aspiration and parenteral fluids. Latterly, however, evidence has been accumulating that after uncomplicated gastric operations some intestinal activity persists in the early postoperative period (Baker and Dudley 1961, Vest and Margulis 1962). Moreover, patients who have had uncomplicated operations have been satisfactorily managed without nasogastric aspiration and with early administration of fluids by mouth or by a duodenal tube (Farris and Smith 1956, Wells and Kyle 1960, Welbourn and Johnston 1961, Hendry 1962). We have been prompted, therefore, to reassess the behaviour of the gastrointestinal tract after gastric operations in patients without postoperative complications, and to study the immediate effects of vagal denervation on alimentary activity, since vagotomy and a drainage is becoming the standard surgical procedure in duodenal tract as a
ulceration.
Group l.-Subdiaphragmatic bilateral vogotomy and wide pyloroplasty for duodenal ulceration (15 patients). Group 2.-Partial gastrectomy with gastroquodenal anastomosis (Billroth i) for gastric ulceration (8 paticnts). Group 3.-Various non-gastric abdominal procedures-e.g., cholecystectomy, small and large bowel resections, and exploratory laparotomy (8 patients). Three radiological contrast agents were used: 1.‘ Gastrografin’(Schering A.G.).-This is a water soluble iodine-containing organic compound which is not absorbed from the intestine; it is innocuous to tissues and is supplied flavoured syrup. filled non-absorbable drug capsules-these were chemically sterilised. 3.’ Solu-biloptin(Schering A.G.).-This is an organic iodine-containing substance which is completely absorbable from the small intestine; it is excreted by the liver and displays the gallbladder well. At operation the abdomen was thoroughly explored in each patient. The immediate postoperative course during which the studies were made, was satisfactory and uncomplicated in all patients; all remained in normal water and electrolyte balance, In the patients who had an operation on the stomach, a nasogastric tube or a temporary gastrostomy tube was passed through the pyloroplasty or gastroduodenal anastomosis and positioned in the second part of the duodenum. In all patients the stomach was aspirated of its fluid and air contents, and barium capsules were placed in the stomach and duodenum in 9 before completion of the gastric closure. Nasogastric intubation was used in 4 of the patients in group 3, but the tubes were left in the stomach. 6 of the patients in groups 1 and 2 were given 3 g. of solubiloptin by mouth as a suspension in water, or down the duodenal tube on the evening of operation. Morphia was administered regularly every four to six hours to all patients for the first twenty-four to forty-eight hours after operation. The radiological studies were begun on the first postoperative day, eighteen to twenty-four hours after operation. All patients at this time had soft, silent abdomens and had passed no flatus per anum. They were clinically in a state of so-called postoperative ileus. Gastrografin (20 ml.) was injected into the duodenal tube, and after screening, a further volume (about 50 ml.) was given by mouth. The contrast fluid was administered in this order so that the medium given by mouth would not obscure that in the duodenum. The oral route only was used in those patients who had not had gastric operations. Radiographs were taken with patients in the supine position immediately after the introduction of the contrast medium, and at intervals of three and six hours afterwards. Further films were taken during the second and third postoperative days, eighteen to twenty-four hours, and forty-eight hours after giving the gastrografin. In the intervals between the radiographs the patients were nursed propped up on pillows (semisitting) without gastric suction, thus ensuring that none of the contrast medium was removed from the’"intestine. In addition to these radiographs, screening under the image intensifier was carried out in 6 patients (3 from group 1; 1 from group 2; and 2 from group 3) during the administration of the gastrografin by both routes, and intermittently for about thirty minutes afterwards. Cine-radiographic recordings were made of these studies. A general picture of the behaviour of the gastrointestinal tract after various abdominal operations was thus constructed from a combination of immediate screening and interval as a
2. Barium
radiographs. Results
Materials and Methods Patients of both sexes and various ages were studied radiologically after the following types of operation:
Gastric
"
Activity
In the three groups, swallowed gastrografin collected in the fundus and cardiac end of the stomach, where it
that the serum alkaline phosphatase in normal pregnancy varies from about 6 King-Armstrong units at thirty weeks up to a maximum of 12 units at forty-three weeks. In this case the alkaline phosphatase rose to 63 units, which is
unusually high even findings are similar to Ohlsson (1959).
acute
M.B.
in this syndrome. The X-ray those described by Svanborg and
be excluded-namely, drugand bileduct calculi. There is no induced jaundice evidence that chlorpromazine or other hepatotoxic drugs were taken by this patient at any stage in either pregnancy, and the final cholangiogram seems to exclude calculi. Neither the history nor the biochemical tests suggest any of the more severe types of jaundice met with in pregnancy-i.e., haemolytic jaundice, jaundice associated with hyperemesis or eclampsia, or obstetric Two other
COMMON MENSTRUAL SYMPTOMS
OF THE MEDICAL RESEARCH COUNCIL UNIT FOR RESEARCH ON THE
EPIDEMIOLOGY OF PSYCHIATRIC ILLNESS, DEPARTMENT OF PSYCHOLOGICAL MEDICINE, UNIVERSITY OF EDINBURGH
causes must
yellow atrophy.
"
Silver " stools are said to be passed in several disorders associated with a disturbance of fat metabolism
(MacNalty 1961). Ogilvie (1955, 1963) suggested that the silver " stool was diagnostic of carcinoma of the ampulla of Vater, and that it was produced by the combination of a clay-coloured stool and simultaneous slight bleeding high in the alimentary tract (Thomas’s sign). It does not seem to have been reported before in obstetric "
hepatosis.
In this case it was attributed to the administration of oral iron in association with the stool of obstructive jaundice. Such stools have since been reproduced by giving oral iron to jaundiced patients (Creamer 1963). Thorling believes that obstetric hepatosis is due to incomplete intrahepatic biliary obstruction precipitated by hepatic damage, whose cause remains obscure. Nixon et al. (1947) and Svanborg and Ohlsson (1959) by liver biopsy have demonstrated biliary thrombi in the canaliculi and mild degeneration. Nixon et al. in 1947 advised termination in "jaundice of pregnancy ", but since then the correct treatment has been shown to be conservative. Besides prematurity, there seems to be no danger to the baby, and there is no evidence that the liver is permanently damaged. My thanks are due to Mr. G. W. Garland and Dr. B. Creamer for permission to publish this case. REFERENCES
Barnes, C. G. (1962) Medical Disorders in Obstetric Practice; p. 113, Oxford. Comerford, J. B. (1962) J. Obstet. Gynœc. Brit. Cwlth. 69, 1022. Creamer, B. (1963) Personal communication. Friedberg, V. (1962) Geburts. u. Frauenheilk. 22, 109. McAllister, J. E., Waddell, J. M. (1962) Amer. J. Obstet. Gynec. 84, 62. MacNalty, A. S. (1961) The British Medical Dictionary. London. Nixon, W. C. W., Egeli, E. S., Laqueur, W., Yahya, O. (1947) J. Obstet. Gynœc. Brit. Emp. 54, 642. Ogilvie, H. (1955) Brit. med. J. i, 208. (1963) Personal communication. Samuels, B. (1961) Obstet. Gynec. 17, 103. Sheehan, H. L. (1961) Amer. J. Obstet. Gynec. 81, 427. Svanborg, A., Ohlsson, S. (1959) Amer. J. Med. 27, 40. Thorling, L. (1955) Acta. med. scand. 151, suppl. 302, 1. Vincent, C. R. (1957) Obstet. Gynec. 9, 595. Von Woert, M. H., Kirsner, J. B. (1961) Gastroenterology, 40, 633. —
"... I am sure that this policy of upgrading people’s skills and qualifications all through life is going to be one of the essentials of the age of automation ... We shall have to do much less in the way of stuffing youngsters at school or university or technical college with present-day knowledge, and much less in the way of equipping them for this or that job in lifefor the present-day knowledge may be useless in ten years and the job non-existent. We shall have to put the emphasis instead on learning how to continue learning, on training young minds in such a way that they are both able and eager to enter into new fields of knowledge and skill from time to time all through their lives as changing conditions require."-S. LILLEY, Nature, Lond. 1963, 198, 1137.
NEIL KESSEL Cantab., M.R.C.P., D.P.M.
ALEC COPPEN Brist., D.P.M.
M.D.
OF THE MEDICAL RESEARCH COUNCIL NEUROPSYCHIATRIC RESEARCH UNIT. CARSHALTON. SURREY
THE work measure the
reported here is the first part of a study to frequency of symptoms before and during menstruation, and to relate such symptoms to personality type. There have been many estimates of the prevalence of dysmenorrhoea, all of which have shown it to be common, especially among young girls. But these results have been based upon considerations of selected groups of the population such as schoolgirls (Golub et al. 1957), students (Schuck 1951), Service personnel (Drillien 1946), and factory workers (Bickers and Woods 1951). The prevalence of premenstrual symptoms has been measured
study, 30% of factory applied for treatment of these symptoms. Pennington (1957) suggested that 95% of American women suffered from premenstrual symptoms at one time only rarely.
In Bickers and Woods’
workers had
another. In all these inquiries the prevalence of symptoms has been determined either by interview or by questionnaire. The subjectivity of the symptoms makes them peculiarly liable to influence by the wording used to ascertain their existence. We thought, therefore, that a standard questionnaire would provide more consistent and reliable information than an interview. We could not share the view put forward by Davis (1938), in his monograph on dysmenorrhoea, that " it is advisable to discount statistics based upon questionnaires, depending as they do upon the patient’s own assessment of her disability ". Only the patient experiences her symptoms. Who else can be competent to assess them ? Of course, women vary in their descriptions of the character of menstrual pain and of its site, its timing, and its duration, and no single physiological or pathological process accounts for the complaint in every woman. Nevertheless, both in common parlance and in medical jargon, a global term is used to embrace all these items, and it is to cover this broad symptom of pain with the periods that we use the medical term for painful menstruation. We would emphasise that this inquiry deals only with symptoms, and that we have no objective evidence of the subjects’ behaviour. Reliable correlations between menstrual symptoms and personality required data from a representative sample of the population. Since symptoms are influenced by such factors as age, civil state, and parity it was necessary to use a normal population group. We were particularly anxious to avoid the serious pitfall of basing conclusions upon a study of patients. Not all women with menstrual symptoms complain to their general practitioners; few of those who do are referred to a gynaecologist, and fewer still to a psychiatrist. Important selective factors are at work, and these bias any group of patients that is studied. Some psychiatrists have even formed their theories from the examination of patients referred for a completely different condition. Reliable conclusions about the significance of psychological factors require, first, a knowledge of the or
62
prevalence of menstrual symptoms in a population sample; and, secondly, correlation of such symptoms with personality type. Method 500 women of menstrual age were chosen from different parts of England by a two-stage sampling method. Ten general practitioners known to one of us or obtained from the research register of the College of General Practitioners (none of them had expressed special interest in either gynaecology or psychiatry) were approached, and from the lists of each a random sample of 50 women between the ages of eighteen and fortyfive was drawn. The first sampling stage was not random; if the selection of doctors introduced a bias, randomising the second stage could not eliminate this. Checks were, therefore, built into the design so that atypical results from any practice would be discovered. After a pilot study based on 50 subjects, a definitive questionnaire was drawn up concerning common menstrual symptoms. TABLE I-THE PRACTICES AND THE SAMPLE
This, together with the Maudsley Personality Inventory, was to each subject with a covering letter outlining the As command of English is purpose of the investigation. necessary to complete the personality inventory we excluded any woman whose name clearly indicated that English was not her first language. During the survey 76 subjects were replaced by others from the same doctor’s list, if we learned that they had moved away, or in some instances because they told us that they were no longer menstruating. Otherwise, no subjects were replaced. If no reply had been received, follow-up letters were sent at intervals of one, two, and four weeks after the original inquiry. The distribution of the practices, and the response to the questionnaire are shown in table I. 54% of the sample responded to the initial approach, 80% after one reminder, and 89% after two. The third reminder raised the response-rate to the very satisfactory level of 93%.
posted
TABLE III-PREVALENCE AND SEVERITY OF MENSTRUAL SYMPTOMS
Subjects were asked to select which of these words best described how they felt: 54% said depressed, 30% tense, 10% nervous, and 6% anxious. t 80% of those reporting swelling mentioned " stomach or abdomen", 54% mentioned breasts, 9% mentioned feet or ankles.
*
were
asked their age, their civil state, their
parity,
and whether
they were menstruating at the time of completing the form. Except for these last personal questions all other responses were made by putting a cross in an appropriate box. We have considered significant only those results which are beyond the 1 % level of probability. Results * The age, civil state, and parity of the sample are shown in table II. There is a small deficit of women aged eighteen to nineteen and aged forty-five, but otherwise the sample is unremarkable. 22 % of the women were menstruating at the time of completing the form, which is slightly but not significantly more than would be expected on the basis of a five-day flow and a twenty-eight day cycle. We later learned that some women had kept the questionnaire until their next period before completing it. Those menstruating when they filled in the form did not differ from the rest in frequency or severity of menstrual symptoms. 82% of the women had regular periods. 3% were unsure if they were regular or not, and 16% were so irregular that they did not know when the next period would come. The prevalence of the various symptoms is shown in table iii, and the time when they were worst in the figure. Correlations that were found between symptoms are shown in table IV. TABLE IV-SIGNIFICANT CORRELATIONS BETWEEN MENSTRUAL SYMPTOMS
The Questionnaire Questions were asked about pain, irritability, depression, anxiety, nervousness or tension, and headaches. Subjects were asked to rate these on a four-point scale-nil, slight, moderate, and severe. They were also asked about swelling of the body, and they had simply to indicate whether this occurred and in what site. For each of these symptoms they were asked the time in relation to the periods when it was worst, and also whether they suffered from the symptom between periods. Other questions concerned regularity of the menses and reduction in normal daily activity during them. Respondents TABLE
II-AGE, CIVIL STATE, AND PARITY
OF
SUBJECTS
P<0’01 for all figures given. N.s. =not Rank correlation coefficient T.
significant.
These tables and the figure should be consulted when the results for individual symptoms are described in turn. Late responders exhibited the same prevalence figures as those who needed no reminding.
Dysmenorrhaea Dysmenorrhoea
was
experienced
to a severe
degree by 12%,
moderate or severe degree by 45% of all subjects. It was maximal on the day the period started. Its prevalence was unaffected by marriage, but it declined with parity; severe period pain was experienced only half as often after the birth of the first child, and moderate symptoms were reduced after the second (table v). This negative association of pain and parity is
and
to a
we present only those results which relate to the prevalence of symptoms and the characteristics of the population. Results
here
concerning personality 1963).
and Kessel
are
being published separately (Coppen
63
statistically significant. There is a similar negative correlation between pain and age; however, using partial rank-correlation coefficients, we have been able to show that the decline in dysmenorrhcea with parity remains statistically significant even when the effect of age is controlled. Dysmenorrhoea is the most important of all menstrual symptoms in causing reduction of everyday activity. Dysmenorrhoea is significantly correlated with menstrual irrita-
Reduction in Activity Each subject was asked to assess the effect of her periods on her everyday life. 21% of women reduced their activities, but only 7% were appreciably affected by their menstrual period. 1 woman in 36 spent some extra time in bed.
bility, depression, headaches, It is sensations of swelling, &c. unrelated to regularity of the periods. Psychological Symptoms Each subject was questioned about menstrual irritability, and whether she became depressed,
The prevalence of menstrual symptoms is very high. More than 1 woman in 9 reported severe degrees of pain, of irritability, or of headache in association with her periods; and 1 woman in 16 reported that she gets very depressed or tense. 4 out of 5 women are conscious of swelling of the body, 1 in 14 restricts her activities during menstruation, and 1 in 7 has irregular periods. Clearly only a fraction of these people bring their symptoms to the doctor, and few of those who do are referred to the gynxcologist or the psychiatrist. Certain symptoms-irritability, depression and tension, headache and body swelling-cluster in a temporal relationship. They are all maximal one or more days before the period begins, and they are significantly intercorrelated, so that a woman who experiences one is likely to experience the others. They form a syndrome conforming closely to that described by Frank (1931), by Rees (1953a and b), and by Greene and Dalton (1953). Epidemiological support is thus given to clinical observation. In fact, the syndrome is far more widespread than has been believed hitherto, moderate or severe degrees of it occurring in about a quarter of all women. The high prevalence of reported sensations of swelling in the breasts and abdomen premenstrually is not readily explicable in the light of the finding by Bruce and Russell (1962) that water retention did not regularly occur in the premenstruum. It is possible that the sensation of swelling is related to a redistribution of water and electrolytes between intracellular and extracellular compartments of the body. Such a redistribution is found in cases of severe depression (Coppen and Shaw 1963), and perhaps the study of physiological changes in depression and menstruation may show common factors which are related to the regulation of mood. Dysmenorrhoea is significantly correlated with the premenstrual syndrome; but here an interesting feature emerges. We compared the timing of dysmenorrhoea in women who complained of the premenstrual syndrome with that in women without this symptom. Of those with the premenstrual syndrome and dysmenorrhcea this symptom developed before rather than during the period in 40%, compared with only 22% of the rest of the subjects with dyamenorrhoea in whom it developed before the period. This difference is significant. It seems, therefore, that one sort of period pain occurs premenstrually and can be regarded as an uncommon feature of the premenstrual syndrome, while the more usual type is worst during the period and is not part of the syndrome.
Differences between
Practices The differences between the various practices in the prevalence of menstrual disorders were not important. Menstrual irritability was significantly low in the Bloomsbury practice, but only 30% of the subjects there were married. This is because a high proportion were university students. Subjects who were registered with women doctors had not any increased prevalence of menstrual symptoms. Discussion
anxious, nervous, or tense around the time of her period; and she was asked to select which of these words best described how she felt at the time. In addition to irritability, most women who
experienced psychological symptoms selected depression and tension as the best descriptive words. worst
They
These symptoms are before the period starts. are significantly correlated
The time, relative to menstruation, when the various symptoms were said to be at their worst.
with headaches, swelling, and reduction in activity during menstruation; but they are correlated with parity, nor with age. Irritability, however, significantly increased by marriage (table v).
Menstrual Headaches Menstrual headaches, although they showed
a
slight
not was
pre-
ponderance before the period began, were more evenly distributed before and during the period. The table of correlations shows an association between dysmenorrhcea and other menstrual symptoms, and also that headaches played a part in reducing normal activity during the periods. In contrast to dysmenorrhoea, headaches are positively correlated with age and parity.
Swelling Subjects
were asked if they had any swelling of the body round about the time of their periods, and if so to state where it occurred. No less than 72% reported some swelling; of those who did 4/5 cited the breasts and 1/2 mentioned the abdomen; only 1/10 indicated feet or ankles; and negligible numbers mentioned the face, neck, fingers, or hands. The symptom was much worse premenstrually. Swelling was correlated with most of the other menstrual symptoms, and with reduction of everyday activity during the periods. TABLE V-EFFECT OF MARRIAGE AND OF PARITY ON DYSMENORRHCEA AND THE PREMENSTRUAL SYNDROME
Summary The prevalence of symptoms associated with menstruation has been measured in a population sample of 500. In all cases it was high.
64
Pain
was worst on
the first
symptoms which tended
day of the period. The other
in the same women were worse premenstrually. Thus there are two very common but distinct entities-the premenstrual syndrome and to occur
dysmenorrhoea. We should like to express our thanks to the general practitioners who assisted us in this research: Dr. R. F. Fairweather, Dr. H. C. Faulkner, Dr. D. M. Grant, Dr. C. F. Hingston, Dr. B. Kessel, Dr. Kathleen Lane, Dr. I. G. McGregor, Dr. Betty Margetts, Dr. J. M. Rea, Dr. A. Ryle, and Dr. J. L. Skene. We are most grateful to Mr. P. M. Payne, director of the South Metropolitan cancer registry, for his assistance and advice in the statistical analysis of the data. REFERENCES
Bickers, W., Woods, M. (1951) Texas Rep. Biol. Med. 9, 406. Bruce, J., Russell, G. F. M. (1962) Lancet, ii, 267. Coppen, A. J., Kessel, N. (1963) Brit. J. Psychiat. (in the press). Shaw, D. (1963) To be published. Davis, A. A. (1938) Dysmenorrhoea. London. Drillien, C. M. (1946) J. Obstet. Gynœc. Brit. Emp. 53, 228. Frank, R. T. (1931) Arch. Neurol. Psychiat., Chicago, 26, 1053. Golub, L. J., Lang, W. R., Menduke, H., Gordon, H. C. (1957) Ame J. Obstet. Gynec. 74, 591. Greene, R., Dalton, K. (1953) Brit. med. J. i, 1006. Pennington, V. M. (1957) J. Amer. med. Ass. 164, 638. Rees, L. (1953a) J. ment. Sci. 99, 62. (1953b) Brit. med. J. i, 1014. Schuck, F. (1951) Amer. J. Obstet. Gynec. 62, 559. —
—
EARLY POSTOPERATIVE GASTROINTESTINAL ACTIVITY N. G. ROTHNIE Lond., F.R.C.S.
M.S.
SENIOR REGISTRAR
R. A. KEMP HARPER M.D. Edin., F.R.C.P.E., F.F.R. DIRECTOR, DIAGNOSTIC X-RAY DEPARTMENT
B. N. CATCHPOLE Manc., F.R.C.S.
M.D. ASSISTANT
ST.
DIRECTOR, SURGICAL UNIT
BARTHOLOMEW’S HOSPITAL, LONDON, E.C.1
STANDARD surgical teaching today is that the alimentary result of reflex inhibition invariably becomes inactive after major abdominal surgery (Aird 1957, Cokkinis 1957, Le Quesne 1957, Jamieson and Kay 1959, Maingot 1961, Farquharson 1962). The period of inactivity, or postoperative ileus, is thought to last for up to three days, according to the operation, during which time the patient is tided over by gastric aspiration and parenteral fluids. Latterly, however, evidence has been accumulating that after uncomplicated gastric operations some intestinal activity persists in the early postoperative period (Baker and Dudley 1961, Vest and Margulis 1962). Moreover, patients who have had uncomplicated operations have been satisfactorily managed without nasogastric aspiration and with early administration of fluids by mouth or by a duodenal tube (Farris and Smith 1956, Wells and Kyle 1960, Welbourn and Johnston 1961, Hendry 1962). We have been prompted, therefore, to reassess the behaviour of the gastrointestinal tract after gastric operations in patients without postoperative complications, and to study the immediate effects of vagal denervation on alimentary activity, since vagotomy and a drainage is becoming the standard surgical procedure in duodenal tract as a
ulceration.
Group l.-Subdiaphragmatic bilateral vogotomy and wide pyloroplasty for duodenal ulceration (15 patients). Group 2.-Partial gastrectomy with gastroquodenal anastomosis (Billroth i) for gastric ulceration (8 paticnts). Group 3.-Various non-gastric abdominal procedures-e.g., cholecystectomy, small and large bowel resections, and exploratory laparotomy (8 patients). Three radiological contrast agents were used: 1.‘ Gastrografin’(Schering A.G.).-This is a water soluble iodine-containing organic compound which is not absorbed from the intestine; it is innocuous to tissues and is supplied flavoured syrup. filled non-absorbable drug capsules-these were chemically sterilised. 3.’ Solu-biloptin(Schering A.G.).-This is an organic iodine-containing substance which is completely absorbable from the small intestine; it is excreted by the liver and displays the gallbladder well. At operation the abdomen was thoroughly explored in each patient. The immediate postoperative course during which the studies were made, was satisfactory and uncomplicated in all patients; all remained in normal water and electrolyte balance, In the patients who had an operation on the stomach, a nasogastric tube or a temporary gastrostomy tube was passed through the pyloroplasty or gastroduodenal anastomosis and positioned in the second part of the duodenum. In all patients the stomach was aspirated of its fluid and air contents, and barium capsules were placed in the stomach and duodenum in 9 before completion of the gastric closure. Nasogastric intubation was used in 4 of the patients in group 3, but the tubes were left in the stomach. 6 of the patients in groups 1 and 2 were given 3 g. of solubiloptin by mouth as a suspension in water, or down the duodenal tube on the evening of operation. Morphia was administered regularly every four to six hours to all patients for the first twenty-four to forty-eight hours after operation. The radiological studies were begun on the first postoperative day, eighteen to twenty-four hours after operation. All patients at this time had soft, silent abdomens and had passed no flatus per anum. They were clinically in a state of so-called postoperative ileus. Gastrografin (20 ml.) was injected into the duodenal tube, and after screening, a further volume (about 50 ml.) was given by mouth. The contrast fluid was administered in this order so that the medium given by mouth would not obscure that in the duodenum. The oral route only was used in those patients who had not had gastric operations. Radiographs were taken with patients in the supine position immediately after the introduction of the contrast medium, and at intervals of three and six hours afterwards. Further films were taken during the second and third postoperative days, eighteen to twenty-four hours, and forty-eight hours after giving the gastrografin. In the intervals between the radiographs the patients were nursed propped up on pillows (semisitting) without gastric suction, thus ensuring that none of the contrast medium was removed from the’"intestine. In addition to these radiographs, screening under the image intensifier was carried out in 6 patients (3 from group 1; 1 from group 2; and 2 from group 3) during the administration of the gastrografin by both routes, and intermittently for about thirty minutes afterwards. Cine-radiographic recordings were made of these studies. A general picture of the behaviour of the gastrointestinal tract after various abdominal operations was thus constructed from a combination of immediate screening and interval as a
2. Barium
radiographs. Results
Materials and Methods Patients of both sexes and various ages were studied radiologically after the following types of operation:
Gastric
"
Activity
In the three groups, swallowed gastrografin collected in the fundus and cardiac end of the stomach, where it