3. Membranous Dysmenorrhoea.
Definition. Membranous dysmenorrhoea is painful menstruation accompanied by the discharge of larger or smaller pieces, tube- shaped portions, or pear-shaped sacs forming complete casts of the lining membrane of the uterus. Pathology and Aetiology. It must be understood at the onset, that the membrane cast off in this form of dysmenorrhoea is not a plastic exudation due to a croupy or diphtheritic endometritis, as was once supposed, but, that it consists of more or less of the lining membrane of the uterus. Various theories have been advanced to account for this process, but none of them have been fully established. Dr. Williams, London, contends, as do many others, that, “the whole, or a large amount of the mucous lining of the body of the uterus is cast off at every period. In health this is accompanied by a fine disintegration, giving rise to no pain or visible phenomena. Under certain as yet obscure conditions, however, disintegration of the mucous coat does not take place, though expulsion does.”
Dr. Oldham claims “that at some time during the intermenstrual period, the entire lining membrane of the uterus is lifted from its base and separated, so as to be ready for extrusion at one of the next menstrual crises.” How this is accomplished, and why it occurs in only a small number of women and not in others, is still unknown, but it is generally supposed to result from inflammation or congestion. Scanzoni attributes it to “a considerable hyperaemia of the wall of the uterus, which is followed by an excess in the development of the mucous membrane.” Simpson attributes it “to an exaggeration of a normal condition, or to an exalted degree of a physiological action.” It has also been claimed that the membrane was deciduous in its character, the product of an abnormal conception, but as it occurs in women who have never had sexual intercourse, this theory has been discarded. Winckel, who is one of our reliable authorities, says that, “the membrane shows the changes characteristic of endometritis; therefore, the term endometritis dissecans is not inappropriate.” Dr. Winterburn says that, “it should be noted that the membrane thus thrown off is not the product of the present catamenial epoch, but of the preceding one.”
Winckel thus describes the anatomical appearance of the membrane: “These membranes show a smooth reddish inner surface upon which the orifice of the utricular glands maybe seen by the naked eye, and an external rough uneven surface, which appears as though torn from its connections, and it occasionally contains small blood clots. It is of unequal thickness, is usually very thin and almost transparent at the points where the walls join each other, and somewhat thicker at those portions where the mucous membrane has not been uniformly exfoliated. In many cases the discharged membrane is a complete sac containing three openings corresponding to the os uteri and the orifices of the tubes. Sometimes this exfoliative endometritis is associated with an exfoliative colpitis; large pieces of membrane, consisting of ulcerated pavement epithelium, are discharged, nd these are followed by tenacious fibrinous portions like those thrown off after the application of a concentrated solution of alum; yet I have seen such a colpitis dissecans occur in a virgin who had not used injections.”
The microscope shows an excess of round small cells and fibrillated tissues, the former being easily differentiated from the large irregular cells of a decidual membrane.
Symptoms. The symptoms vary much in intensity in different individuals, in some the membrane being discharged regularly with but little pain. Ordinarily the period is introduced by slight pains which gradually increase in intensity, until they become violent and expulsive, like the pains or abortion, and cease only when the membrane has been expelled, which is usually on the second or third, or more rarely, on the fourth day. The flow is not always profuse, being sometimes quite scanty, and not infrequently the membrane plugs up the cervix so that the blood is retained, and is discharged in clots after the expulsion of the membrane. The time between the periods is usually free from pain, but the patient usually feels weak and miserable, and may complain of various symptoms which are the result of existing complications.
Diagnosis. The nature of the pains and their regularity with each menstrual membrane expelled, are usually sufficient for diagnosis, but it may be necessary to submit the latter to a microscopical examination in order to differentiate either from an early abortion, or, less often, blood-casts or fibrinous moulds of the uterus, or exfoliations of the vaginal mucous membrane, or the exudation of diphtheritic endometritis.
Prognosis. This is usually considered unfavorable, though if treatment be commenced at an early stage a cure may be effected. The disease is not dangerous to life, though it may become associated with complications that are sometimes fatal. Sterility is a usual consequence of membranous dysmenorrhoea, but cases are reported where conception has occurred in advanced stages of the disease.
Treatment. The hygienic measures already suggested for neuralgic dysmenorrhoea should, to some extent at least, be applied in this variety. From our present knowledge of the pathology of this disease it is impossible to deny that some dyscrasia is at its foundation, which may be partially overcome by a proper attention to the diet and habits of the patient. By some it is claimed that the disease occur only in persons of a rheumatic diathesis, and if so, it is especially necessary that the patient be protected from atmospheric changes. She should wear flannel next the skin continually, and so far as possible enjoy the benefits of a mild, dry and even climate.
Relief is sometimes obtained by having the patient anticipate the period a few hours by going to bed and applying heat to the abdomen, sacrum and extremities.
Various methods of treatment, such as dilatation of the uterine cavity, discission of the cervical canal, cauterization of the uterine mucous membrane, have been resorted to by old- school authorities with negative results. Dilatation of the cervix with tents often affords relief. On this point Dr. Ludlum says: “Very decided benefit may sometimes be derived from the employment of the spong tent, with a view to dilate and remove any obstruction of the cervix which prevents the free escape of the menstrual blood. This would cause the womb to disgorge, unload its capillaries, relieve the hyperaemia, avert an excessive hypertrophy of the mucous membrane, and possibly prevent its exfoliation. Moreover and it is by no means an inconsiderable thing this dilation greatly mitigates the sufferings of the patient.”
The remedies most often used are: Borax, Bromine, Bryonia, Calcarea carb., Cantharis, Caulophyllum, Iodium, Rhus tox., Colchicum, Collinsonia, Kali iod. Phosphorus, Gelsemium, Secale, Ustilago For the nervous and other concomitant symptoms that may arise, many other remedies may be indicated. See indications at the end of this chapter.
4. Obstructive Dysmenorrhoea.
Definition. A variety of a dysmenorrhoea dependent upon a partial or complete closure or obstruction of the genital canal, causing an impediment to the free escape of the menstrual discharge which collects above the obstruction and is only expelled by violent spasmodic pain. The obstruction most often exists in the cervical canal or at t he os, but it may be in the vagina or at the vulva.
Aetiology. The causes of obstructive dysmenorrhoea are: Atresia of the cervix of vagina, congenital or acquired; atresia of the hymen; stenosis of the cervix, congenital or acquired; flexion or version of the uterus, the former creating an angle in the canal, the latter less often causing in the canal, the letter less often causing obstruction by firm pressure of the os against the vaginal wall; forbid tumors in the cervix, causing distortion of the canal; uterine polypus obstructing the cavity or neck, often acting as a ball valve at the os internum, preventing the egress of fluids, but allowing the passage of a probe.
Symptoms. No symptoms are manifest until a sufficient amount of blood has accumulated within the uterus to cause distension, when spasmodic contractive pains are excited for the purpose of over-coming the obstruction. The pains gradually become more and more severe, the expulsive efforts resembling those of abortion, thought more painful. Finally a discharge, of more or less blood results and the pains are relieved until the accumulation has again taken place, when the process is repeated. The flow sometimes comes drop by drop, but more often the uterine contractions are followed by gushes, the blood being frequently clotted, the clots sometimes corresponding in size and shape of the uterine cavity.
In many cases, especially if they have existed for a length of time, more or less reflex symptoms are present. Vomiting is quite a common symptom, which is often obstinate and painful in character. There may also be indigestion, rectal and vesical tenesmus, and nervous, disorders, such as insomnia, chorea, hysteria, cramps, and even convulsions.
ALLEN CORSON COWPERTHWAITE was born at Cape May, New Jersey, May 3, 1848, son of Joseph C. and Deborah (Godfrey) Cowperthwaite. He attended medical lectures at the University of Iowa in 1867-1868, and was graduated from the Hahnemann Medical College of Philadelphia in 1869. He practiced his profession first in Illinois, and then in Nebraska. In 1877 he became Dean and Professor of Materia Medica in the recently organized Homeopathic Department of the State University of Iowa, holding the position till 1892. In 1884 he accepted the chair of Materia Medica, Pharmacology, and Clinical Medicine in the Homeopathic Medical College of the University of Michigan. He removed to Chicago in 1892, and became Professor of Materia Medica and Therapeutics in the Chicago Homeopathic Medical College. From 1901 he also served as president of that College. He is the author of various works, notably "Insanity in its Medico-Legal Relations" (1876), "A Textbook of Materia Medica and Therapeutics" (1880), of "Gynecology" (1888), and of "The Practice of Medicine " (1901).