l/ VI- MITTELSCHMERZ. By J. Halliday Croom, M.D., F. R.C.P. Ed., F.R.S.E., Physician to the Royal Maternity Hospital; Physician to, and Clinical Lecturer on Diseases of Women, Royal Infirmary; Lecturer on Midwifery and Diseases of Women, School of Medicine, Edinburgh. (Communicated by Dr Haultain.) I DO not propose to enter into a general discussion of dysmenorrhea. The object of the present communication is to discuss a form of dysmenorrhea, by courtesy so called, which occurs, not at the period when the external manifestation of men- struation takes place, but at mid-term,?a condition to which the " Germans have given an appropriate name, Mittelschmerz," and " which the French have, less felicitously, called Dysmenorrh^e intermenstruelle." Whatever name may be applied to it?and certainly intermenstrual dysmenorrhea is not suitable?the con- dition is a well-marked one, wherein an attack of dysmenorrhea proper is simulated, without, necessarily, any external haemorrhage. It does not at all resemble the pre-menstrual pain, or the continued pain associated with inflamed or diseased ovaries, but it is a con- dition which occurs definitely each month, at a definite period, and for a definite number of days. So far as I am aware, the condition was first of all described by MITTELSCHMERZ, BY DR J. HALLIDAY CROOM. 27 Sir William Priestly many years ago, and it has been also dis- cussed by Fasbender and Sorel. I will now recount the more important points of a case occur- ring in my own experience, which may be taken as fairly typical. It was that of a young girl of 18 years of age, whom I first saw at Prof. Simpson's private clinique somewhere about the year 1873. She complained of acute pain, sometimes in one side and sometimes in the other, occurring with the utmost regularity, fourteen or fifteen days after her menstruation. This had been the case ever since she was 14, and she did not begin to menstruate until she was 16. There was no abnormality, so far as I could discover, in the ovaries, tubes, or uterus. I saw her more or less regularly for thirteen or fourteen years after she first came under my observation. During all that time she menstruated with regularity, and her intermenstrual sufferings continued. During the years I knew her she occupied various situations in the capacity of a housemaid. She menstruated regularly and without pain, but every month she was obliged, in order to avoid her intermenstrual suffering, to use morphia rather freely. She ultimately married and went to the Colonies, and I know nothing of her subsequent history. Her pain began after a very severe attack of scarlet fever when she was about 14 years old. The second striking case that has come under my personal observation was that of a woman who was sent to my ward for profuse haemorrhage, associated with marked dysmenorrhcea, in addition to a definite and severe pain occurring between the men- strual periods, about the fifteenth day. The pain was severe and localised to the left side, and accompanied occasionally, though not always, by a slight discharge, sometimes of blood, and sometimes of clear fluid. On examination she was found to have a uterus enlarged to 3^ inches, and containing a submucous fibroid on the right side. After continued treatment, including curetting, she was sent home, but returned in a few months with the symptoms all con- siderably aggravated. It was resolved, therefore, with a view to checking the haemorrhage, which had become so profuse as to prevent the patient continuing her duties, to remove her append- ages. This was done; the right ovary was somewhat cystic and the tube thickened; on the left side the ovary was normal, but there was a well-marked hydrosalpinx. It is worthy of note, as bearing directly upon the case, that the woman was 35 years of age, and she had suffered from intermenstrual pain only for five years. It will therefore be seen that this case differed entirely from the last one, in which the condition of intermenstrual pain had existed from childhood. Two things, consequently, are clear about this case,?first, that the condition was distinctly an acquired one. Were it due to some condition of the ovary, then the Mittelschmerz should have 28 MlTTELSCflMEKZ, BY DR J. HALLIDaY CHOOM. been on the right side, whereas the pain was on the left, where the ovary was normal. Secondly, if it were due to painful ovulation occurring independently of menstruation, then it would have been expected that the intermenstrual pain would not have been of such recent origin. It is therefore by no means unlikely that this rare condition may be due to the over-distension of the Fallopian tube with fluid, and that the pain of the Mittelschmerz is associated with its expulsion. This question of hydrops tubse profluens I shall discuss later on. Case 3.?A woman, 25 years of age, was brought to St Luke's Home some years ago suffering from severe dysmenorrhcea, the dysmenorrhcea occurring for the first three days of the menstrual period. Various remedies were prescribed, but she returned to the Home some months afterwards, being no better. A local examina- tion was then made, when it was found that the uterus was some- what enlarged and acutely retroflexed. The condition of the appendages was apparently normal. During her stay in the Home, which was rather protracted, and before any operative interference had been undertaken, my atten- tion was drawn to her having acute suffering in the left side, about fifteen days after menstruation, very similar to the pain she suffered at her menstrual period, but not so severe. I examined her then, and found the condition in the pelvis as I have described, with the addition that there was a distinct fulness at the left side, the nature of which, at the time, I did not recognise. On further inquiry, I found that she had had this mid-term pain, lasting for a few hours, regularly for four or five years. With a view to curing her dysmenorrhcea the cervix uteri was dilated, and she was sent off in the hope that her dysmenorrhcea would be relieved. Months later she was brought back again by her mistress, who said she was quite unfit for her duties as a servant, and must therefore, unless cured, leave her situation, all the more so as twice in the month she was temporarily hors die combat. I am not perfectly sure what the further treatment was which she underwent for her dysmenorrhcea, but, whatever it was, it was unavailing. The case was brought to me after I came to be in charge of beds in the Infirmary, and after carefully considering the matter with the doctor in whose charge the patient had been, I somewhat unwillingly removed the ovaries. I found that there was well- marked hydrosalpinx of the left tube. The fact that this condition of the hydrosalpinx, of the size of a small hen's egg, was not found except on the one occasion referred to above, led me to the con- clusion that it was one of those cases of hydrops tubae profluens, and this conclusion was entirely supported by the subsequent history of the case; because, although the removal of her ovaries and tubes neither stopped her menstruation nor cured the dys- MlTTEiiSOHME HZ, BY DR J. HALL1DAY CKOOM. 29 menorrhcea, the intermenstrual pain did not recur for at least a year afterwards, since which time I have not heard of the case again. The four cases recorded by Priestly in the British Medical Journal for 1872, which appear to be the earliest recorded cases presenting this condition, have the following as their prominent features:?Pain, paroxysmal, in the region of the ovary, occurring during the intermenstrual period ; in some cases continuing up to the commencement of the flow, in others stopping before then. The ordinary flow is usually scanty, but regular, and with no pain. On Bimanual Examination.?In two cases tumour felt in region of broad ligament, adherent to uterus, elastic to touch. In the other two cases only thickening in the region of the broad ligament. Sorel records a case, presenting symptoms similar to those mentioned above, in which the condition existed for a great number of years; indeed, observation had been made during a period in which 147 menstrual epochs had occurred. The chief conclusion arrived at by this author was that the occurrence of the intermenstrual pain bore a more definite relation to the com- mencement of the period which followed it than to the period which went before, as there always elapsed fourteen days between .the occurrence of the pain and the commencement of the menstrual period. One of the most important contributions to the very limited literature of this subject is an article by Heinrich Fasbender, pub- lished in 1876, in the Zeitschrift fur Geburtshiilfe und Frauen- JcranJcheiten. The case, which he quotes as having occurred in his own experience, presents the following features :? An unmarried woman of 24, anaemic, with an anxious cast of countenance, had menstruated regularly since her fourteenth year. The flow was always sparing, and for a few days before its appear- ance there was a severe pain in the lower part of her abdomen, with gastric disorder, cachexia, and alternate sensations of heat and cold. For the past two years there had occurred, at the four- teenth to sixteenth day after menstruation, a disorder similar to that which accompanied the ordinary menstrual period, accom- panied by a flow of mucus from the vagina so conspicuous as to have caused her to mention it without its being suggested to her.