LECTURES ON GYNECOLOGY.—BY FRANKLIN

H. MARTIN, M. D., Professor of Gynecology, Post
Graduate Medical School, Chicago.

DYSMENORRHOEA.

I want to talk a few minutes this morning on a subject that is practical, and one that is discussed in our text-books too little that subject is dysmenorrhoea, painful menstruation, and I wish to discuss it from the standpoint of nonoperative treatment, or at least of other than radical treat

ment.

Dysmenorrhea in Young Girls.-One of the most frequent conditions you will have to deal with as gynæcologists, or as general practitioners, is that of the dysmenorrhoea occurring in young girls. The history of a case will be about as follows: The patient will tell you that she had severe cramping pains which began at the first menstruation. She will give a history of having at this time, and without relief, the most excruciating pain in the lower part of the abdomen, which was considered at first intestinal colic. The pain was so severe that the girl was quite overcome, so that she threw herself upon the bed or upon the floor and cried out with the severity of distress. Never before having menstruated the girl was, of course, in ignorance of any possible cause for the attack. The pain lasted for two or three minutes and then gradually disappeared. In five or ten minutes there was another paroxysm, possibly of even greater severity than the first, which after a minute or two again disappeared. After awhile, with the most trying pains that could be described, there was noticed a slight flow of blood from the vagina and after that the suffering grew less and less until the menstrual flow was free. This condition continued month after month,

with the use of only the ordinary household remedies for relief, until finally a physician was called, who gave anodynes. The girl had been strong and healthy before these painful periods. Since having them, however, she had begun to grow nervous and irritable, and finally to lose flesh, and at the time she consulted the gynæcologist her nutrition was poor, her skin white or yellow and more or less bloodless, and she was extremely nervous and hysterical.

You immediately suspect from this history the condition. which you should find existing in the particular case. You picture to yourself immediately, if you have had experience, the conditions existing in that girl's pelvis. The symptoms are severe enough so that you are justified in asking for a pelvic examination to confirm your diagnosis. If you are positive from the history that the conditions are what you suspect them to be, nothing but treatment of some kind will relieve them. Theretore insist upon an examination.

Now you are under more or less of a disadvantage in these cases unless you have a reputation as a gynæcologist and unless the patient is brought to you with the expectation that an examination is to be made; and you will have all the prejudices to contend with that are usually urged against the examination of a virgin. But under the circumstances, with such a history, you should demand a vaginal examination of this girl, with the idea of being able to institute proper treatment. This should be advised firmly and insisted upon. It is inevitable, and you should insist upon the examination and proceed promptly to make it.

Vaginal Examination of Virgins.-It is possible, however, to make this examination without producing excessive pain. There are certain ways to manage these cases so that the patient will not be deterred from further treatment in the progress of the case.

In order to examine a virgin it is well, as a preliminary to the digital exploration, to place over the vulva between the small labia, a portion of cotton saturated with cocain, in the

same way that you would anesthetize a nasal cavity. It is never necessary, in making an examination of this kind, to use more than the index finger of one hand. Nothing can be gained by using two fingers, and the index finger of one hand alone should be employed; and no speculum as a rule is necessary. Therefore, if you have to make an examination of a very nervous patient whose vagina is virgin, employ but one finger well anointed with an oil containing cocain.

The examination should be made with extreme care and if you have plenty of time it is better to take two or three sittings to make this examination rather than have the patient suffer to the point that you will be unable to accomplish any results afterwards. With care, and with the idea of not making the examination all at once, should it be very painful, proceed to carefully press upon the posterior portion of the vulva, and gradually insert the finger until the cervix is reached. The exploration will reveal the fact that the cervix is very low in the pelvis. By bi-manual manipulation, .conducted carefully, you can examine the outlines of the uterus and the appendages.

If no treatments were likely to follow an examination, the proper course to pursue would be to conduct the investigation under ether anæsthesia.

Condition Revealed by Examination. The local condition which you will find revealed here will be an undeveloped, ante-flexed uterus. You will come upon the cervix as a long, pointed, soft body lying parallel with the vagina, instead of at right angles to it. In your examination of the body of the uterus above, you will find a little knob of a fundus coming forward at right angles to the cervix You will find this cervix extremely soft, and that it contains little more than connective tissue and the mucous membrane surrounding it and lining its cavity, together with a very little muscular tissue. The muscular coats of the uterus are materially undeveloped. With the finger in front of the cervix, then, instead of finding the uterus a continuation of the cervix,

which would reveal it cf necessity in retroversion, you will find it in acute anteflexion. In palpating the appendages you find them normal, possibly a little undersized.

Cause of the Pain at Menstruation.-What is the cause of this dysmenorrhoea? It is this. Instead of having an actual organic stricture at the internal os, you have a bend of the uterus at that point which shuts off the calibre of the uterus and produces an obstruction or a flexion as effectually as you can close the calibre of a rubber tube by bending it at right angles. Blood accumulates in the uterus above this point on the approach of menstruation, and that blood acts as a foreign body, as in the case of a small foetus, a piece of placenta, a mucous polypus or any foreign body in the same place, and as the uterus has very little muscular tissue, it requires an enormous amount of stimulation before this small, undeveloped muscular body will respond; but finally, through the influence of stimulation, it will respond and attempt, by violent contraction, to discharge this foreign substance. If the uterus were not bent the blood would flow forth from the canal without pain; but under the circumstances the distention becomes marked. The uterus in its effort to empty itself contracts with clonic, painful paroxysms which produce the most severe distress. These clonic contractions resemble labor pains; and this continues until the uterus is exhausted, or until the obstruction is overcome. If the force of contraction is strong enough so that the blood begins to flow through the obstruction, then there is less suffering at the next contraction.

Therefore, as the result of a bend in the uterus at the internal os the pain is produced. This continues each month, if nothing is done to relieve it, or if it does not relieve itself spontaneously (which is rare), and by degrees there appear the general nervous disturbances that we get from any painful irritation of the pelvis, whether it is from a retroversion, a tumor, inflammation, diseased appendages or dysmenorrhoea. At first the sympathetic nervous irritation which disturbs the

rhythm of the organs of the body, the heart, stomach, intestines, kidneys and others, which, in turn, disturbs the general nutrition of the patient, and as a consequence of this we get a general anæmia, and then disorders of the general nervous system.

TREATMENT.

We have made out our diagnosis. What shall we do for the patient? Unfortunately there is no operation known that will cure this condition. It must necessarily be relieved by some form of treatment. If we had an organic stricture We could eradi

of the os, we could relieve it by dilitation. cate the long, snout-like neck of the uterus by amputation, but in so doing we would accomplish absolutely nothing to develop the muscles in the walls of the uterus and prevent the continuance of an anteflexion. The difficulty here is that we have a uterus soft and non-developed and in such an embryonic state that a flexion is favored. To overcome this in rational manner we should do something to develop the uterus. The reason this cervix is an inch-and-a-half long, instead of an inch, is not because it is hypertrophied in its long diameter, but it is because the sac of mucous membrane covering the cervix has nothing in it, or not enough in it. If you develop the muscular coat of this cervix you will increase the diameter of the part; and in increasing the diameter you will naturally shorten it, at least in a relative sense. The reason this uterus is soft, long and flabby is because it is not filled out with muscular tissue. If you fill it up with muscular tissue, it will become plump and of normal proportions. If you should split this uterus and get a profile of the cut surface, you would find that at the point of flexion, the thinnest point of the wall of the uterus, the muscle tissue was less developed than at any other. Therefore it is necessary to fill up that chink; but to do this we must first straighten the uterus. Now it is obvious that in order to develop the contents of this sac, which is like a loose stocking with nothing in it and which is