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11-1955 UWOMJ Volume 25, Number 4, November 1955 Western University

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This Book is brought to you for free and open access by the Digitized Special Collections at Scholarship@Western. It has been accepted for inclusion in University of Western Ontario Medical Journal by an authorized administrator of Scholarship@Western. For more information, please contact [email protected], [email protected]. Office Gynaecology W. Pelton Tew, M.B., F.R.C.S., Edin. & Can., F.R.C.O.G.

The term gynaecology means the treat­ Special articles of equipment: This ment of diseases peculiar to the female would include a biopsy punch (sterilized), genitalia, and office gynaecology, of an Ayres spatula for taking cervical course, refers to the management or treat­ smears, a microscope and suitable stains, ment of the diseases peculiar to the fe­ a small incubator is very handy, insufflator male genitalia and these diseases are such for treating trichamona and some special that one is able to properly manage or solutions or powders used for specific to treat them in the office. Besides this, treatments of trichamona and the yeast of course, there are certain diagnostic fungus, an electric cautery for cervical procedures which may be carried out in catarrh cases. Other special items may be the office. The same rule applies in the added as found necessary. office as in the hospital, namely, before Your gynaecological patients may be you can properly treat any disease you divided into three common groups: must firstly arrive at your diagnosis. There are three cardinal essentials for (a) the young adoleJcent patientJ. aiming at a proper diagnosis: (b) patientJ in the child-bearing age. (a) a good clear cut hiJtory. (c) the menopau1al and poJt-menopauJal (b) a general phyJical exami1zatio11. patientJ. (c) the functional inquiry. Before carrying out a pelvic examina­ With these in mind you are prepared to tion for the younger patients, you must proceed with your diagnostic investigation. have the patient's mother or guardian present and obtain her consent before do­ ing a pelvic examination. Such a patient ESSENfiAL OFFICE EQUIPMENf may be examined by rectum at first and if necessary the vaginal examination may For a proper and thorough examination be done under an anaesthetic. This patient of any gynaecological patient you will must be 18 years of age before she need at least certain essential articles of accepts responsibility herself regarding equipment, such as : a private and well­ pelvic examination. The common reasons lighted room, an examining table with a for the younger patients seeking advice moderately firm mattress, a goose-neck from a gynaecologist are as follows: light or one similar, adequate supply of clean linen, including sheets for draping (a) late puberty. the patient, a tray on a table beside the (b) irregular periodJ. examining table and this tray should in­ (c) epimeno"hea. clude the following at least: a bivalve (d) meno-metrorrhagia. speculum, sponge forceps, gauze or cot­ ton wipes, waste dish, culture tubes, glass (e) vaginal diJrharge. slides for smears, sterile applicators for (f) lower abdominal pain. taking smears and a pair of clean gloves. (g) enlargement of the lower abdomen. •Professor of Obstetrics and Gynaecology, University of Western Ontario.

NovEMBER, 1955 97 ---Office Gynaecology------

We usually do not worry about late symptoms and a feeling of something puberty until the girl is 16Yz years old, coming down, and bleeding. Post-meno­ providing she is a reasonably healthy girl. pausal bleeding means carcinoma from Also the irregular periods need cause no some pelvic organ until you prove it is special concern until she is 16Yz years not. A definite diagnosis of such bleed­ old. Meno-metrorrhagia requires a thor­ ing will usually always require a cervical ough investigation - including a gen­ biopsy and/or a dilatation and curettage. eral physical examination, a pelvic ex­ amination and usually always a dHatation and curettage. SOME FINAL HELPFUL LESSONS The women in the child bearing period 1. A good history is invaluable. of life present themselves with more mul­ 2. Do not hurry with the history or ex­ tiple complaints and of course require amination - if you do, you will meticulous investigation. The commoner miss something important. complaints might be summarized as follows: 3. Remember that about 25% of your patients will not have any very seri­ (a) having missed a period. ous gynaecological lesion at all, but (b) irregular periods. will be emotionally disturbed. Pro­ (c) vaginal discharges. per psychological management of (d) pain or discomfort rn lower ab- these patients will pay dividends. domen and back. Remember also that about half of the 25% of patients will not have (e) urinary symptoms. any organic gynaecological lesion (f) any combination of these. whatsoever and only need moral help. If a woman misses a period at this time 4. All women 30 years old or older of life she is pregnant until you prove should have a thorough pelvic ex­ she is not. Meno-metrorrhagia or epi­ amination every six months or more menorrhea require a diagnostic curettage often if necessary for selected cases. always. Suspicious cervices should be biopsied. The vaginal discharges should 5. Pre-requisites for a pelvic examina­ ~ treated according to the causative or­ tion - a cooperative patients in pro­ ganism. Pain is often a baffling problem per position and draped, an empty and will try your investigative powers to rectum and bladder. If the bladder the fullest. The commonest causes of pain is full pass a catheter and not an in this age group may be: opinion. If the rectum is full give an enema before giving a gynaeco­ (a) extrinsic. logical opinion. (b) intrinsic. 6. Post-menopausal bleeding means can­ Extrinsic causes are those outside the cer until you prove it is not. female genitalia or pelvic viscera. In­ 7. Remember there are three possible trinsic causes are those within the female sources of bleeding whenever a wom­ genitalia or pelvic viscera, such as en­ an complains of pelvic bleeding: dometriosis, pelvic inflammatory diseases and ectopic pregnancy. (a) from the cervix or uterus. (b) from the urethra or bladder. Older women at or after the meno­ (c) from anus or rectum. pause come to you with a different symp­ tomatology, e.g., vaginal discharges, vul­ Check all three carefully before mak­ var irritations, vaginal bleeding, urinary ing a final decision.

98 U.W.O. MEDICAL JOURNAL 8. Psychological disturbances are com­ pregnant without 100% good rea­ mon around the time of menopause son, because she may some day come and will require actually more skill back pregnant for sure. in their management than most of 10. Sprinkle a little common horse sense the organic lesions. in all your therapy and it will pay 9. Never tell a patient she cannot get dividends every time.

THE DIAGNOSTIC ACCURACY OF that is the percentage of false nega­ THE VAGINAL SMEAR IN CANCER tives was 6.2% plus or minus 1.5%. This was corrected to 2.0% plus or OF THE UTERINE CERVIX minus 0.9% by the removal of those cases in which the presence of malig­ 01/e Kiillgren; A cta Obstetrica et Gyneco­ nant cells could have been masked logica, Scandinavica, Vol. 34, No.3, 1955. by recent previous treatment.

(c) Of the 16 false negatives, 5 were .A brief review of the development of adenocarcinoma; that is 5 of 13 cases exfoliative cytology with special refer­ or 38% of adenocarcinoma were in­ ences to the gynecological field and correct while 11 of 244 cases or 4.3% Papanicolaous' technique opens this article. of squamous cell carcinoma were .A discussion of the techniques of taking incorerct. smears, of staining, and of the exami~a­ tion of smears is followed by a descnp­ .According to the author's statistical tion of the celluar elements of a normal analysis, this difference, though large, smear, the criteria of malignancy, and the is not significant, being compatible celluar types found in cases of uterine with the results of other investigators. cervical carcinoma. (d) Thirty-eight cases or 15% were of There are two major diagnostic errors endocervical origin. Of the 16 false possible in the technique: (a~ false ne¥a­ negatives, 9 were endocervical; that tive diagnoses are those w1th negative is 9 of 38 cases or 24% of endo­ smears but positive cancer on biopsy; cervical carcinoma were missed or (b) false positives with positive smears incorrectly diagnosed, while only but no cancer present. 3.2% of portio vaginalis carcinoma were so misdiagnosed. This differ­ The present study involves 257 cases ence is statistically significant, prob­ of uterine cervical cancer found in the ably due to the higher incidence of examination of 3000 smears. The follow­ adenocarcinoma of the endocervix. ing statistics were derived: The author feels that false negative (a) 244 or 95 % were squamous cell car­ diagnoses would be reduced if the smears cinoma, only 13 cases or 5% were were taken from the endocervical region adenocarcinoma. rather than from the vaginal pool. (b) There were 241 correct and 16 false negatives diagnosed from the smears, -Bob McLachlin, Meds '57

NovEMBER, 1955 99 Normal Menstrual Physiology

Kay Sandor, Meds '58

INTRODUCTION The phenonema of estrus in the lower animals an.d the menstrual cycle have been well known for many years. However, the exact mechanism and processes involved were comparatively unknown until recently. In 1917, Stockard and Papanicolaou discovered that the vaginal mucosa under­ goes a cyclic histological change during the menstrual cycle. This evidence stimu­ lated a further study of the cycle. Allen and Doisy produced an estrogenic sub­ stance capable of producing estrus in ovarectemized cats in 1923, followed by the ccystalization of estroge.n in 1929 by Doisy, and finally the isolation of estrogen from ovarian tissue in 1935. Even after the isolation of the estrogenic substances, it was found that the menstrual cycle could not be experimentally produced. Corner and his associates in 1929 demonstrated the presence of the second ovar­ ian hormone which was produced by the corpus luteum and which when used with estrogen was capable of experimentally reproduci ng the menstrual cycle. There ace still many facts in dispute, but the author of the following paper has set forth to elucidate and review the present concepts of the normal physiology of the menstrual cycle.

HISTOLOGY ates the thicker but more loosely con­ structed functional layer which is sloughed The normal human uterus is described off during the bleeding period. histologically as consisting of three coats from without inwards: Blood Supply 1. Serous coat or visceral peritoneum The uterine arteries, branches of the 2. Muscular coat or myometrium internal iliacs, supply the endometrium. 3. Mucous membrance or endometrium The functional and basal layers, however, receive separate arteriolar blood supplies Menstruation is more particularly con­ via the straight arteries to the basal layer, cerned with the endometrium; this layer and the coiled or spiral arterioles to the will be given a more detailed description. functional layer. The straight and spiral The endometrium or the lining of the arterioles pass from the myometrium to uterine cavity has an epithelium of col­ the endometrium, the straight arterioles umnar cells and a lamina propria, usually ending directly in the basal layer while referred to as endometrial stroma, of the coiled or spiral arterioles end in a mesenchymal cells enmeshed in a network spray of precapillary arterioles in the of reticular fibres. The columnar epi­ functional layer. thelium also lines the simple tubular glands which are scattered through the Length of the Menstrual Cycle stroma and which open into the uterine cavity. The menstrual periods begin at puberty, between the ages of ten to fifteen years, The endometrium consists of two dis­ and continue at regular intervals until the tinct layers, the deeper basal layer and menopause, which occurs between the ages the superficial functional layer. The thin of forty-five to fifty. In the very early compact basal layer remains unchanged years of menstruation, it is not abnormal during the menstrual cycle and regener- or unusual if there is no regular per-

100 U.W .O. MEDICAL JOURNAl iodicity of menstrual bleeding and amenor­ ioles into the necrotic adjacent endome­ rheal periods of several months to a year trium and then sloughing occurs. may occur toward the end of the teens. The menstrual discharge consists of However, a regular interval between men­ blood (50%-75% of the total volume), strual periods is usually established. mucus, endometrial tissue and desqua­ The interval between successive men­ mated vaginal epithelium. Since menstrual struations is usually accepted to be twenty­ blood does not dot rapidly, it is assumed eight days for academic discussions of the that some factor is present in the endo­ menstrual cycle. Clinically, a cycle ranging metrium which will dissolve any clots from twenty-one to forty days is con­ formed in the uterine cavity. sidered to be within normal limits. 2. Proliferative or Estrogenic Stage Length of the cycle is important for more than academic reasons. It has been This stage commences when the dam­ successfully used in the calculation of the age from menstrual stage has been com­ most fertile periods in women of lowered pletely repaired (fifth to sixth day) and sterility, and also for evaluation of the continues until the fourteenh day of the infertile periods for contraceptive reasons. cycle (for eight or nine days). During this stage the endometrium Stages of the Menstrual Cycle grows from less than a millimeter in (Histological Changes) thickness to two or three millimetres. The epithelial cells composing the glands 1. Menstrual Stage and covering the endometrium are low The menstrual period proper is con­ columnar at this stage; most of these sidered the first stage in the menstrual secrete a watery mucous material, but cycle and its length varies from three to patches of nonsecretory, ciliated cells are seven days with the day of its onset con­ scattered among the others. The glands sidered to be the first day of the cycle. are narrow and pursue a straight course through the functional layer. Also termed the dismantling phase, it consists of the sloughing off of the func­ .. tional layer of the endometrium, leaving 3. Progestational or Secretory Stage the basal layer intact. The entire func­ Assuming that ovulation occurs on the tional layer is not destroyed over the en­ fourteenth day of the cycle, the proges­ tire inner uterine surface at any one time; tational phase begins on the fifteenth sloughing occuring over small areas. day and continues until the twenty-eighth After the functional layer has been shed day, which is the final day, or until the from one small area, repair of that area onset of the next menstrual cycle. from the basal layer begins almost im­ mediately as the sloughing process con­ During this stage the endometrium in­ tinues in other areas. creases to about four to five millimeters in thickness, by the following mechanisms: The sloughing occurs as the direct re­ sult of the constriction of the spiral (1) mitosis of exist.ant stromal cells arterioles. This constriction is thought to (2) enlargement of stromal cells set in twenty-four hours before any bleed­ (3) accumulation of tissue fluids in ing and to continue for several hours. intracelluar spaces Necrosis results from the arteriolar con­ ( 4) accumulation of glandular secretion striction, the arteriolar walls weaken. As the spiral arterioles relax, blood oozes The glands remain as in the estrogenic out of the weakened walls of the arter- stage in the superficial part of the func-

NOVEMBER, 1955 101 --Normal Menstrual Physiology'------

tional layer, but in the basal layer and 2. Progestational or Secretory Stage the deeper part of the functional layer (Fourteen-Twenty-eight Days) they become elongated, coiled and dilated. The corpus luteum, under stimulation The mucous secretion of the glands be­ of L.H., secretes progesterone, which acts comes thicker. The endometrial cells be­ on the endometrial mucosal and glands. come high columnar in character and effecting further proliferation of ·the accumulate glycogen particles between mucosa and increased secretory activity. their nuclei and free borders. As the progesterone level increases, the The endometrium is now fully pre­ production of F.S.H. is inhibited and no pared for the implantation of the fer­ further follicular development occurs. If tilized ovum. The ovum had been re­ pregnancy occurs, the corpus luteum con­ leased normally half way through the tinue to grow and secrete progesterone. cycle, if fertilized, the growing ovum If no fertilization occurs, the corpus would then be successfully implanted. If luteum eventually ceases to function and fertilization does not occur, the menstrual becomes the corpus albicans, through the period commences and the cycle is following mechanism: as the proges­ repeated. terone level in the blood rises, the pro­ duction of L.H. by the anterior pituitary is inhibited, and at the same time the Ovarian and Hormonal 0tanges estrogen level has fallen and there is no During the Cycle stimulation for the production of L.H. 1. Proliferative Stage Since L.H. is essential to the development (Fifth to Fourteenth Day) and continuation of the corpus luteum, when it is no longer produced or when During this period, under the stimula­ its blood level falls, the corpus luteum is tion of F.S.H., follicle stimulating hor­ deprived of stimulation, the progresterone mone secreted by the anterior pituitary level falls, allowing the release of F.S.H., gland, a new follicle has developed, is which reiniates the cycle. growing, and is stimulated to produce the hormone estrogen. Estrogen acts on the 3. Menstrual Cycle uterus of the mature female, bringing (First to Fifth Day) about the proliferative stage. This hor­ mone also keeps the female sex organs At onset of menstruation a primordial in a mature developed state, and initiates follicle is developing in the ovary and the at puberty the development of the sec­ corpus luteum is degenerating. There are ondary sex characteristics. By the four­ several conflicting theories as to the exact teenth day the blood level of estrogen excitant of the menstrual bleeding. They is such that the anterior pituitary is stimu­ are in brief: lated to release L.H. or luteinizing hor­ (1) Esrogen deprivation after corpus mone which first acts on the follicle, luteum degeneration when the blood level causing its rupture. Regardless of the of estrogen is extremely low. This has length of the menstrual cycle, it is now been substantiated by experimentally iniat­ accepted that ovulation occurs about fif­ ing menstrual bleeding after ovariectomy. teen days before onset of flow. L.H. con­ Conflicting evidence is that menstrual tinues to act on the ovary, causing the flow can also be initiated by large doses development of the corpus luteum in the of estrogen. cavity of the ruptured follicle. The cor­ pus luteum being formed from both the (2) Progesterone deprivation following cells of the ruptured follicle and also corpus luteum degeneration. However, ovarian stromal cells. this theory is untenable when it has been

102 U.W.O. MEDICAL JoURNAL shown that progesterone often evokes Menstrual bleeding is frequently con­ bleeding in amenorrheal women. current with various mild physical com­ plaints even in the completely normal It is more plausible that it is due to a woman. Among these are headaches, deprivation of both estrogen and proges­ fatigue, backache, pelvic pain and breast terone which initiates and evokes mens­ tenderness. Nervousness and depression trual flow. are not uncommon before actual bleeding (3) Acetyl choline stimulated by the begins. presence of estrogen may bring on hyper­ aemia and bleeding. BmLIOGRAPHY ( 4) An unknown endometrial bleeding BEST and TAYLOR: Physiological Basis of factor has been suggested as being present Medical Practise, 1950. in human females and in the Rhesus CURTIS and HUFFMAN: Textbook of Gyn­ monkey. This factor is postulated as act­ ecology, 1950. ing upon the spiral arteries of the func­ HAM: Histology, Second Edition. MAZER and ISREAL: Menstrual Disorders and tional layer to bring about arteriolar Sterility, 1946. spasm and thence bleeding. WRIGHT: Applied Physiology, 1952.

ENDOMETRIOSIS: THE RESULTS abdominal endometriomata. 85% of their OF CONSERVATIVE SURGERY cases fell into group (a), 54% of these cases were followed up with the follow­ D. B. Whitehouse, M.D.M.R.C.O.G. and ing results: 70% were completely cured A. Bates, M.B.D.Obst.R.C.O.G. The of symptoms. The pregnancy rate was Journal of Obstretrics and Gynecology of 45% , the recurrence rate was 33%, but the British Empire, June 1955, Volume only one-half of these cases required radi­ LXII, No.3. cal treatment.

The treatment of endometriosis during In this discussion the authors state that the past 40 years has gone through a com­ each case presents an individual problem. plete cycle. When first explained by Samp­ They feel that it is better to err on the son in 1921, endometriosis was treated by conservative side rather than the radical conservative surgery. The next century when operating. Medical treatment is dis­ found radicle surgery widely practised. cussed and compared. They doubt that The pendulum now swings back to con­ medical treatment will give better results servative surgery with preservation of re­ and feel that too often after trial medi­ productive function and relief of symp­ cal treatment the disease is too extensive toms the first principle in the treatment for conservative surgery. For young wom­ in younger women. en and older women, still wanting chil­ dren, the. first principle is to relieve symp­ The authors divided the operations into toms while preserving the child-bearing. three groups: (a) resection of pelvic en­ This can best be achieved in a high pro­ dometriosis preserving reproductive func­ portion of cases by conservative surgery. tion; (b) total hysterectomy conserving ovarian tissue; (c) excision of extra- -Robert Martin, Meds '56

NoVEMBER, 1955 103 Endocrinology In Gynaecological Practice

• Earl R. Plunkett, M.D., PhD.

INTRODUCI10N It is the purpose of this communication to discuss in general terms a few of the endocrine or pseudo-endocrine problems which may present in gynaecologic.al practice. Many such conditions are associated with abnormalities of uterine bleed­ ing and it should be clearly understood that all such patients must be given a thorough pelvic investigation.

History taking, as in all branches of Rather obvious but often overlooked, medicine, should be thorough, and al­ conclusions may be drawn from history though the patients now under considera­ and examination which assist in deter­ tion present with gynaecological symp­ mining the function of the pituitary­ toms, a gynaecological history alone is by ovarian axis. Uterine bleeding indicates no means sufficient. To assess the status, adequate follicle stimulating hormone pro­ it is helpful to determine any symptoms duction and an estrogen producing ovary, referable to each of the glands. For ex­ provided that pelvic pathology is excluded ample, opposite thyroid, the state of ther­ and the very rare feminizing adrenal mal tolerance, condition of skin, bowel hyperfunction does not exist. Since gon­ function, etc., is recorded. Details of adotrophin is usually depressed very early previous treatment, particularly endocrine in all types of hypopituitarism, uterine treatment, is very important since admin­ bleeding is a very important observation istered hormones may influence the type in diagnosis. of investigation and treatment to be used. Administration of thyroid causes depres­ ln a similar fashion, breast develop­ sion of the production of thyroid stimu­ ment can only occur in the presence of lating hormone from the pituitary with estrogen and if a patient complains of a consequent reduction in intrinsic thyroid delay in the menarche, breast growth activity. This results in a depression of helps to rule out hypopituitarism and the radioactive iodine pickup, while a ovarian aplasia. B.M.R. may be elevated. ln a similar manner, estrogen therapy decreases the The nutritional state of the patient is production of pituitary gonadotrophin often important in determining the pres­ found upon urinary assay and Cortisone ence of endocrine disease. ln spite of the lowers the level of adrenocortical func­ fact that marked cachexia is frequently tion. Furthermore, endocrine therapy for described as a symptom of hypopituitarism one target gland affects the functions of it is very rare that such is the case. Most others via the pituitary. For example, instances of depressed pituitary function estrogen produces an increase in the are not absolute and it is possible that plasma protein-bound iodine (Engstrom only in the presence of gross glandular an

104 U.W.O. MEDICAL JOURNAL of depressed pituitary function have anor­ disease. This latter is the function of the exia nervosa. full curettage. Very marked obesity is almost never due to endocrine disease except in rare ENDOCRINE DISORDERS OF THE instances of a lesion involving the hypo­ thalamus. Hypothyroid patients may tend PREPUBERTAL EPOCH to be overweight but are seldom grossly Endocrine disorders of this age group obese. Obesity is often accompanied by are relatively rare but when they do a lowered B.M.R. due to increased skin occur are usually of considerable magni­ surface and the low oxygen requirements tude. Sexual precocity including uterine of fat tissue. bleeding before the age of nine or ten Certain simple endocrine tests may be years should be regarded with suspicion. carried out in the office to determine the Apart from a few patients with a physio­ adequacy of estrogen production. These logical early puberty occurring in the particularly apply to patients with amenor­ borderline age, the commonest cause of rhoea. A sample of mucus from the cervi­ precocity is the granulosa cell tumour of cal os may be spread on a glass slide and ovary. Such patients tend to be tall for allowed to dry. The appearance of fern­ their age because of the growth promot­ like crystals is indicative of estrogen pro­ ing effect of the sex steroids, but due to duction. With practice, the vaginal smear, the early closure of the epiphyses, eventual suitably stained, shows a high percentage short stature is the rule. Breast develop­ of epithelial cells with pyknotic nuclei ment and gynecoid fat distribution is upon estrogen stimulation. Uterine bleed­ present along with axillary and pubic ing following two or three intramuscular hair. Uterine bleeding tends to be irregu­ injections of 50 mg. Progesterone at forty­ lar and if followed over several months eight hour intervals is diagnostic of a no definite cycle is in evidence. Usually good estrogen level; sufficient to main­ recto-abdominal examination, provided tain the endometrium. This latter test the patient is relaxed, will reveal a pelvic is also used in the early diagnosis of preg­ tumour 4 to 8 em. in diameter. Apart nancy, since bleeding does not occur in from an elevated excretion of estrogen the presence of a fertilized ovum. in the urine, hormone assays are of little value in this age group. Theca cell ovar­ The diagnosis of ovulation may be ian tumours and estrogen producing made by doing an endometrial biopsy adrenal lesions may produce a similar with the Novak suction curette. It is clinical picture but are exceedingly rare. best done within the first twelve hours of bleeding and has the advantages of not Polyostotic fibrous dysplasia (Albright's requiring an anaesthetic, much less cost syndrome) consisting of multiple bone to the patient than a D and C, easier to cysts, cafe au lait areas of pigmentation arrange with regard to timing in the in the skin, and sexual precocity is a rare cycle than a D and C and the patient condition affecting only girls. This may is able to go home after a short rest. be classified as a true type of precocity This procedure is often done in the office since the pituitary actually produces a but in the absence of good sterilizing normal adult level of gonadotrophin re­ equipment for the instruments, the Out sulting in stimulation of the ovaries and Patient Department of a hospital is prob­ consequent development of the second­ ably the place of choice. Under usual ary sexual characteristics and cyclic ovula­ existing circumstances the endometrial tory bleeding. True pituitary precocity biopsy should not be used as a diagnostic rna y also be caused by pineal tumours, method for ruling out local endometrial inflammatory disease or injury in the

NovEMBER, 1955 105 --Endocrinology in Gynaecological Practice------region of the hypothalamus. In the case childish appearance of such a patient per­ of pituitary types of precocity no en­ sists until the third or fourth decade when docrine therapy is indicated, since glan­ a very rapid aging takes place. Complete dular function is essentially normal ex­ failure of the development of secondary cept for time of onset. sex characteristics occurs. Usually there is evidence of decreased thyroid function In all cases of precocity where the eti­ and possibly hypoadrenal function as well. ological factor is amenable to treatment. Such patients should have a thorough en­ efforts should be made at correction. In docrine investigation with effort being instances where an ovarian tumour is made to establish the etiology of the present, surgery should be carried out as pituitary deficiency. Since craniopharyn­ soon as possible. gioma is the commonest pituitary or su­ Delay in puberty with hypoestrogenism prasellar tumour in childhood, X-rays of will now be considered. Evidence of estro­ skull may show calcification in the ·su­ gen production may be seen normally as prasellar area which point to this type of lesion. early as age seven with the beginning of changes in fat distribution. The more The endocrine treatment of hypo­ obvious evidence of breast development pituitarism is directed toward replace­ generally does not appear until the years ment of the hormones which the patient of nine till twelve. Accompanying the is lacking. It should be stressed that even signs of sexual maturation is an upsurge if the deficiency only refers to the gona­ in statural growth under the stimulus of dal hormones, cyclic estrogen therapy does the sex steroids. The menarche usually a great deal to improve the health and occurs between the ages of ten and six­ general well being of the patient. Full teen with the average for this country sexual development occurs, though the being approximately thirteen years. patient will likely remain sterile, and the negative nitrogen balance which tends to Chronic debilitating disease and ex­ be present is to some extent corrected. treme nutritional deficiencies are capable Cyclic estrogen therapy should never be of delaying sexual maturation. However, carried on indefinitely since occasionally in the absence of such conditions, com­ these patients do develop better pituitary plete failure of pubescence at the age of function and are able to get along with­ sixteen or seventeen years warrants a out treatment. Consequently, one or two thorough investigation. Two major pos­ months rest from treatment should be given sibilities exist: failure of the pituitary to after each four or five cycles. As a gen­ produce gonadotrophins or failure of the eral rule pituitary tumours are not sub­ ovaries to respond to the trophic stimuli. mitted to surgery unless pressure on the The former may be the result of a cranio­ optic chiasm begins to cause blindness. pharyngioma or other suprasellar tumours, inflammation, infarction of the pituitary, Failure of ovarian development often gumma, metastases, xanthomatosis or presents with the following findings: congenital absence of the pituitary short stature, webbing of the neck, in­ eosinophiles. creased carrying angle of the forearms, other orthopaedic anomalies, complete If the hypopituitarism begins early in failure of pubescence, mental retardation childhood or is congenital, the statural and a markedly elevated urinary gona­ growth is usually markedly retarded, the dotrophin excretion. This series of symp­ bones are small and development is de­ toms has been called Turner's syndrome. layed, the facies remains childish, the hair is fine and silky, pubic and axillary Ovarian aplasia, however, can occur hair growth is scant or absent and the without all of the above-described find-

106 U.W.O. MEDICAL JOURNAL ings. The two consistent observations, The etiological factors which may re­ however, are a complete failure of sexual sult in postpubescent amenorrhoea are development and an elevated urinary extremely numerous. Almost any en­ gonadotrophin excretion. Treatment con­ docrine disease, debilitating diseases of all sists of replacement estrogen therapy kinds, undernutrition, ovarian cysts and usually given in twenty day cycles with tumours, tuberculous endometritis, and a ten day rest period between. Doses of psychological disturbances may cause ces­ one to two mg. of Stilboestrol or its sation of the menses. All such patients equivalent per day bring about rapid require a very thorough medical and en­ establishment of a gynecoid body habitus, docrine evaluation, including a gonado­ a general improvement in health and a trophin assay. The latter is depressed in feeling of well being. Uterine withdrawal hypopituitarism, elevated where ovarian bleeding frequently occurs with this failure has occurred and usually within regime but the chances of bleeding may the normal range or at the lower limit be increased by giving one to three injec­ of normal in the psychogenic type of tions of 25 mg. Progesterone during the problem. Therapy in all instances should last week of each cycle. The bleeding it­ be directed at the cause of the problem. self is of no importance apart from the psychological benefit which may follow. Of particular interest is the amenor­ rhoea which occurs in the presence of In simple instances of a delayed men­ obesity. Since many grossly obese women arche, where breast development, pubic have cyclic cycles and are fertile, it would and axillary hair growth and gynecoid appear that fat deposition per se is not body habitus has appeared and where no at fault. Hamblen {1953) has observed local abnormality exists in the genital that amenorrhoea is most likely to occur tract, three or four cycles of estrogen and in those patients who suddenly gain a Progesterone therapy as described above considerable amount of weight in a short is usually sufficient to initiate spontan­ period of time. It is very possible that eous periods. the psychological disturbance which stim­ ulates the patient to eat excessively is Postpubescent amenorrhoea or second­ actually the cause of the menstrual prob­ ary amenorrhoea is a relatively common lem as well. Weight reduction and the gynaecological symptom. However, dif­ improvement in general health which ferentiation should be made between the accompanies it frequently results in a re­ patient who is perfectly healthy and has turn of uterine bleeding. relatively few ovulatory cycles per year. Even if the bleeding only occurs three or Amenorrhoea which persists after a dif­ four times a year, this patient is probably ficult or traumatic delivery may be on the better left untreated. In order to rule basis of a focal necrosis of the pituitary, out such patients and also the physio­ producing varying degrees of hypopituitar­ logical lapse of pregnancy, Hamblen has ism. This type of pituitary deficiency has defined amenorrhoea as absence of spon­ been called Sheehan's syndrome. Thor­ taneous uterine bleeding for at least one ough endocrine investigation is required year. If one reviews the literature with to evaluate the amount of endocrine de­ this in mind, it soon becomes apparent ficiency existing. Replacement of gona­ that the very good results reported by a dal, thyroid and adrenal hormones is then wide variety of therapeutic measures is made according to the requirements of primarily confined to that group of pa­ the patient. Although the full picture of tients having infrequent bleeding, while Sheehan's syndrome is not common, re­ the results in the treatment of true cent studies by Schneeberg et al {1953) amenorrhoea are uniformly poor. in women with a history of postpartum

NOVEMBER, 1955 107 --Endocrinology in Gynaecological Practice------hemorrhage or shock has demonstrated tion that this form of therapy is effec­ slight suggestive evidence of decreased tive and it seems quite justified when adrenocortical function. Persistent lacta­ used cauiously after other measures have tion, two or more years following a preg­ failed. Psychotherapy, carbon dioxide in­ nancy or in the absence of any history of halation therapy and electro-shock treat­ pregnancy when accompanied by amenor­ ment have been observed to restore bleed­ rhoea poses a difficult diagnostic prob­ ing in patients under treatment for severe lem. Since nervous stimuli from the nip­ psychopathies. ples are an important factor in the main­ Virilizing syndromes are not common te.nance of lactation following pregnancy, but one is frequently faced with the prob­ the history of prolonged breast feeding lem of hirsutism. Virilization means more or mammary masturbation must be con­ than this, however, and includes voice sidered. Such a combination of symp­ change, prominence of the larynx, oily toms, however, require a careful pituitary skin and acne, increased muscularity, re­ investigation since it occurs in a high per­ gression of the hair at the temples, breast centage of chromophobe and mixed pitu­ regression, amenorrhoea and frequently itary tumours. Such patients should have an increase in libido. These changes may a periodic examination over a period of be due to a virilizing tumour of the three to five years since these tumours ovary, adrenocortical hyperplasia or adren­ may grow very slowly. Endocrine defi­ al tumour. In all cases there is an in­ ciencies may appear four to five years be­ crease of Androgen production which is fore any neurological or radiological evi­ usually reflected in an elevation of the dence of the pituitary tumour appears. urinary 17 ketosteroids. When the viril­ Functional or psychogenic amenorrhoea izing lesion is situated in the adrenal it may persist for years without evidence of is possible to have excessive production hypoestrogenism. These patients usually of other cortical hormones resulting in have a normal or lower limit of normal Cushing's syndrome. A trial of Cortisone follicle stimulating hormone production therapy frequently differentiates tumour but are lacking in luteinizing hormone. of ovary or adrenal from adrenocortical The endometrium is in a resting estro­ hyperplasia by its ability to suppress the genic phase and is capable usually of excretion of 17 ketosteroids in the latter responding to Progesterone with bleed­ instance while failing to do so in the ing. The vaginal mucosa seldom becomes presence of tumour. The presence of a atrophic and breast regression is uncom­ mass in pelvis or the upper part of the mon. The promotion of withdrawal bleed­ abdomen, evidenc~ of renal displacement ing by estrogen and Progesterone cyclic in an intravenous pyelogram and an en­ treatment is successful in a small per­ larged adrenal shadow radiologically after centage of cases m promoting spontan­ presacral air insufflation provides addi­ eous cyclic bleeding. Low dosage irradia­ tional diagnostic evidence. tion therapy of the ovaries and pituitary The treatment of either tumour is sur­ has been studied over three generations gical while the adrenocortical hyperplasia by Kaplan, Rubin and others without can now be treated successfully by main­ encountering genetic effects. Recently tenance doses of Cortisone sufficient to Rakoff and Perloff, independently at the keep the 17 ketosteroids within normal Canadian Society for the Study of Fer­ limits. The usual daily requirement is tility meeting in Montreal, 1954, said they 25 to 50 mg. per day in divided doses. found no difference in the results between Suppression of the adrenal by this ther­ patients treated with pituitary and ovar­ apy via inhibition of ACTH allows the ian radiation and those receiving ovar­ pituitary ovarian function to occur with ian radiation alone. There is no ques- consequent production of estrogen and

108 U.W.O. MEDICAL JOURNAL resumption of uterine bleeding. A viril­ NOBLE, R. L., and PLUNKETT, E. R., Brit. izing process present from birth is usually Med. Bul., 11, 98, 19~~- on the basis of adrenocortical hyperplasia HAMBLEN, E. C., ESSELBORN, V. M., and while appearance of the symptoms later SAWTELLE, W. E., Med. Clio. of N. in life are more likely to be due to tumour. America, 37, 1077, 19H.

BIBLIOGRAPHY SCHNEEBERG, N. G., PERLOFF, W. H., ENGSTROM, W . R., and MARKARDT, B., VIEILLARD, C. B., and ISRAEL, S. L., ]. Clio. Endo. and Metab., 14, 2U, 19~4 . Obst. & Gyn., 1, 1~6 . 19H.

PALLIATIVE TREATMENf OF the vaginal walls and the vault of the PROLAPSE OF THE UTERUS . vagina. These pessaries bend to roll out with the folds of the vagina when there has been too much stretching. Solomon Gold, Montreal. Canadian Medi­ cal Auociation Journal, 1953. Five menopausal women were treated by inserting a rubber bulb into the vagina Prolapse of the uterus usually results after the uterus was displaced (asepto from obstetrical injuries and may be syringe bulb B.D.). The bulb was in­ aggravated post-menopausally when there serted while compressed and folded longi­ is loss of tone of pelvic viscera. Pelvic tudinally by the index finger, the neck pressure, central low lumbar or sacral of the bulb toward the introitus. This pain, urinary and bowel disturbances, supports the vault and pushes the bladder often associated with constitutional and upward and somewhat anteriorly. If the nervous symptoms are common complaints. bulb comes out white stained a larger Cystitis from residual urine may cause bulb is used. frequency, dysuria and even anuria. In complete prolapse, the above symptoms Daily cleansing douches and bimonthly plus difficulty in walking, epidermidiza­ removal and reinsertion is advised. Smaller tion of the cervix, circulatory congestion sized bulbs may be resorted to as the and hypertrophy of the uterus may be introitus becomes smaller. A few months recorded. sees an improvement in pelvic tone and also in urinary and emotional disturb­ Surgery is the treatment of choice. If ances. No damage to vaginal mucosa was this treatment is refused or contraindi­ observed in this series. This treatment cated, palliative therapy is in order. may be of value preoperatively to allow Mechanical devices such as hard ring uterine supporting structures to contract. pessaries or soft rubber doughnuts afford a certain amount of relief by stretching -T. E. Staples, Meds '56

NovEMBER, 1955 109 Dysmenorrhoea

Jocelyn Pearce, Meds '56

INTRODUCTION Dysmenorrhoea h.as been defined .as difficult menstruation and is generally interpreted as pain related to the menstrual cycle, either preceding the onset, during or immediately following the cessation of flow. Until recent times there h.as been little reference to this clinical problem, and this may be partly due to the female reticence in discussing menstrual diffi­ culties with her physician, and partly due to the male .assumption that pain con­ nected with menses is normal. Early references contain mention only to dysmen­ orrhoea as the result of cervical stenosis, "Nulla dysmenorrhoea nisi Obstruc­ tive." However, the causes of this symptom are many, and some are put forth in this paper. It is of paramount importance that we remember that dysmenorrhoea is a symptom only, and although palliative symptomatic therapy is necessary, the prime purpose should be to determine the exact etiological cause and then treat that cause.

The term dysmenorrhoea refers to a importance because of the economic wast­ symptom which is exceedingly common age which it causes. It is well known by and is important both to the specialist in firms that employ large numbers of wom­ the field of Gynecology and to the gen­ en that more working days are lost eral practitioner. If the word is broken through dysmenorrhoea than because of up into its component syllables it will be any other form of ill-health except per­ seen that the literal meaning is as follows: haps the common cold. Efficiency is also difficult; plus month; plus to flow. The lowered appreciably and more accidents word therefore means pain or discomfort occur in factories because of this lowered associated with the monthly menstrual efficiency and concentration. At the risk flow. Many women experience some dis­ of discouraging some of my readers from comfort at this time, but normally they proceeding further, I would like to stress consider it as a minor inconvenience if right at the outset of this article that thev consider it at all. If a little more there is still no ideal treatment for this pai~ occurs the patient may take aspirins condition and no certain cure. This, of or some other readily obtainable drug for course, is no excuse for neglect by the a day or two each month, but not consider physician to examine such a patient thor­ it of sufficient importance to seek a doc­ oughly and attempt conscientiously to tor's help. However, there are a large alleviate her symptoms. number of women who find it impossible to carry on their regular work for a few Types of Dysmenorrhoea days each month; there are others who are forced by the extreme discomfort to Before one can discuss the treatment remain in bed. It is these patients who of this condition intelligently, something come to the doctor for relief from their of the etiology must be known. There distress, and this article is primarily aimed are two clearly demarcated types of dys­ at reviewing the various theories of eti­ menorrhoea. primary and secondary, or, ology and the treatments which have been if you like, essential and acquired. Sec­ and still are being tried in this condition. ondary dysmenorrhoea is due to some Quite apart from the humanitarian point demonstrable pathology in either the pel­ of view, dysmenorrhoea is of considerable vic or the neighbouring abdominal or-

110 U.W.O. MEDICAL JOURNAL gans. There may be some degree of con­ have very little relation to the presence stant pain in these instances, which is or absence of abnormal pain, but the accentuated at the time of mensruation, passage of clots may be painful in some or the pain may only be present at the cases. The character of the pain is again period. It is thought that the increased typical. It is of a crampy, spasmodic congestion of the pelvic organs coinci­ variety, compared by some to miniature dent with menstruation increases the pain labour pains. The spasms may be very of the chronic disease. Primary dysmenor­ severe, and in emotional individuals may rhoea, on the other hand, is defined as be so severe that some patients are re­ pain occurring with the menstrual flow ported to have contemplated suicide. The in the absence of any demonstrable discomfort is sometimes present as an pathology in the pelvic organs. Because aching and a sensation of pressure in the the cause of this type has not been gen­ pelvis, but these feelings are more often erally agreed upon, the treatment also due to secondary dysmenorrhoea. The varies with the individual physician, but latter also differs from primary in that there are several general principles em­ the discomfort tends to occur during the ployed by all which I shall discuss later. flow rather than before it, and fewer of the secondary symptoms such as depres­ Differential Diagnosis sion and emotionalism are seen. It is immediately obvious that before treatment of any definite nature can be­ Secondary Dysmenorrhoea gin, the physician must satisfy himself As can be appreciated, the history of as to the type of dysmenorrhoea present. the discomfort is important in the dif­ ferential diagnosis. Equally important is a thorough general and pelvic examina­ Primary Dysmenorrhoea tion which will often confirm the physi­ There are several factors about the pain cian's impression as to the presence or of the primary type which will help in absence of definite pathology. The com­ this differentiation. It is known that monest pathology one finds in association anovulatory menstrual cycles are painless with this symptom is that of chronic in­ menstrual cycles. This explains the com­ flammation of the uterus and adnexa, and mon finding that the patient with primary it will often be found to have commenced dysmenorrhoea had quite normal periods with childbirth (whereas primary dys­ for a few months to years after the menorrhoea often disappears with child­ menarche, and that the pain commenced birth). It can also be caused by neoplasms when the patient was in her late teens of the pelvis, especially ovarian cysts; or early twenties. Characteristically the occasionally by retrodisplacement of the discomfort commences a day or so before uterus, or by cervical obstruction caused the flow begins, to last until the first in turn by radiation or pelvic surgery. day of the flow. In atypical cases the A history of pain commencing in the pain may be of only a few minutes dura­ mid or late twenties and becoming pro­ tion or it may last throughout the period gressively worse over the years strongly and even for a few days after the flow suggests endometriosis. On the other has ceased. One commonly finds nausea hand, the etiology may he found in extra­ and vomiting, headache or backache, and genital lesions of the bladder, ureter, or a feeling of depression and irritability sacro-iliac joints. The above list is by no accompanying the actual pain. Most pa­ means exhaustive but it gives an indica­ tients complain of constipation, but diar­ tion of the multitude of possible causes rhoea may occasionally be the main symp­ for secondary dysmenorrhoea. It must be tom. The amount of the flow seems to self-evident that permanent relief from

NovEMBER, 1955 111 ---Dysmeno"hea------the pain in these instances depends en­ consideration in primary dysmenorrhoea tirely on the discovery and eradication of and it should be remembered that no one the underlying pathology. Until such has yet explained the fact that pregnancy treatment can be instituted, the pain often effects a cure. can be controlled with rest, local heat to the abdomen, and mild analgesics. Because of the crampy nature of the This temporary control will be discussed pains, it has been suggested that the uterus further under the treatment of primary is overly irritable and undergoes accent­ dysmenorrhoea. uated contractions in those patients who experience severe pain. In order to test this theory, rubber bags were placed in The Etiology of Primary Dysmenorrhoea the uteri of patients with dysmenorrhoea For a great many years gynecologists and the time of the contractions com­ have attempted to discover the cause of pared with that of the cramps. These two this common complaint, but, although phenomena synchronized remarkably well many theories have been advanced and and the contractions did seem to be some apparently proven at the time, the stronger than those measured in normal final answer is not yet known. One of women. This theory seemed to be rea­ the original concepts concerned the pat­ sonable, but it did not explain why the ency of the cervical canal. It was felt contractions were stronger. Since then that a congenitally small canal would ob­ similarly strong contractions have been struct the flow of blood and that the pain observed in persons without any dys­ resulted as the uterus attempted to expel menorrhoea, but this does not entirely this blood. It was demonstrated that the exclude this theory. It may be argued so-called "pin-hole os", or the condition that these latter patients have a higher of acute anteflexion of the uterus (which threshold of pain and so do not complain would also narrow the os) did indeed of it as readily. exist in many of these patients. Under Congenital hypoplasia of the uterus has this assumption the recommended treat­ been noted in quite a few patients and ment was dilatation of the cervix. The therefore has in its turn been considered rationale of this therapy was strength­ as a causative factor. However, it is not ened by the fact that dysmenorrhoea always found and so is not apparently a often ceased after the birth of a baby. necessary factor. Also it must be remem­ Dilatation of the cervix is still recom­ bered that hypoplasia has been recognized mended in some cases, but unfortunately quite frequently in patients who do not much damage was done by over-treat­ complain of menstrual pain at all. This ment. Scarring due to tears of the cervix factor has therefore taken its place with often prevented adequate dilatation of the rest as having some place in the causa­ the cervix at subsequent labours, thus tion of the pain in some patients but be­ materially obstructing these labours. The ing by no means a major factor. It is treatment frequently did relieve the dis­ now postulated that even when hypo­ tress temporarily, but it usually returned plasia is present it is only a sign of an after several months or years, and Novak underlying endocrine disorder which in feels that many of these reported cures turn is the real cause of the dysmenorrhoea. may have been due to the psychic element present in the original condition. It is .An interesting theory, and one which known that many patients have acute ties in with a theory previously men­ anteflexion or the "pin-hole os" men­ tioned, is that of Chassar Moir. He pos­ tioned above with no symptoms what­ tulates that the excess uterine contractions ever. However, some authorities still con­ may increase the intra-uterine pressure un­ sider that cervical stenosis is worthy of til it exceeds the blood pressure, therefore

112 U.W.Q. MEDICAL JOURNAL preventing the entrance of blood into the to be affected by pain. Her physiological uterine vessels. This will cause ischemia pain threshold is lowered. It may be ve~y of the uterine musculature which in turn difficult to decide how much emphaSIS will cause pain on the same principle as should be placed on this aspect and how the pain of myocardial insufficiency. This much on psychogenic factors in any in­ seems to be a reasonable theory as to why dividual patient. One should always be­ the contractions cause the pain, but of gin treatment in these patients by attempt­ course it does not attempt to explain ing to increase their general health and why the excess contractions are present. occasionally this may be all that is necessary. The above theories as to the causation of the pain are not made use of in decid­ As is occurring at the present time in ing on the clinical treatment as extensively almost every field of medicine in which as are the next three theories to be the causation is not definitely known, mentioned. endocrine aberration is considered to be the basic disorder in dysmenorrhoeas The psychogenic theory is the firs~ of which are not purely psychic in origin. these. There is no doubt that there IS a Again there have been many theo~ies large subjective factor in a number of concerning the exact type of endocnne these patients, and the dividing line be­ disorder which would produce the ex­ tween the normal discomfort coincident cess uterine contractions, for the latter with the menstrual flow and dysmenor­ are still considered as the cause of the rhoea is ve~y hard to determine. It must pain. It is agreed that estrog~n increases be decided by the patient herself in a the contractility of the utenne muscle large percentage of cases and it is diffi­ and that probably progesterone decreases cult but imperative for the doctor to it. The pain cannot be due to excess decide whether she has excess pain or is estrogen alone even though this would under the impression that the normal dis­ be a pleasingly simple explanation. The comfort is abnormal. The patient's edu­ pain does not occur right after puberty cation has a great deal to do with this. and it does not occur in functional bleed­ There may be others in her family who ing where it is known that there is ex­ had dysmenorrhoea and she may consider cess estrogen and a deficiency of proges­ that she should feel ill at her periods. terone. The cramps are therefore prob­ This patient may be entirely cured by ably due to an imbalance in the amounts psychotherapy alone. She must be en­ of estrogen and progesterone present, but couraged to be up and about during her just what this imbalance is and in what periods and must be convince~ to . her way it increases the contractility of the own satisfaction that menstruation IS a muscle is still under debate. Nevertheless, physiological rather than a pathological endocrine treatment is directed empiric­ phenomenon. The patient who is under ally towards decreasing this excess con­ emotional tension at home or at work tractility, or towards preventing ovula­ is also a candidate for dysmenorrhoea tion, for an anovulatory cycle is a pain­ and may be cured by psychotherapy alone less cycle. The latter can be accomplished if the physician is able to devote suffi­ by the use of estrogen and the former by cient time to discovering the source of progesterone, testosterone, or chorionic her tension and helping her to over­ hormone. come it. Another of the important factors is Treatment of Primary Dysmenorrhoea constitutional debility. The patient who is the victim of chronic disease, over­ The reader is now familiar with the work, or chronic fatigue is more liable principles of the treatment of dysmenor-

NovEMBER, 1955 113 ---Dysmeno"hea'------

rhoea, but a summary will probably not (2) Attempts at Permanent Relief be amiss before I commence the discus­ After a physical examination has been sion in detail. There are three divisions done to rule out any possible pathology, in the treatment: a careful interview is necessary in order ( 1) Relief at the time of the attack. to determine what role, if any, psycho­ genic factors play in the particular case (2) Attempts at permanent relief. under treatment. If one decides that there (3) Endocrine therapy. are not any underlying emotional fac­ tors, then one can proceed with other These treatments are based mainly on the definite treatments. However, if tension four present theories of causation: is seen to be a major factor then the phy­ sician is wise to start his treatment along (1) Psychogenic. these lines. The patient may not need (2) Constitutional debility. anything but psychotherapy, or it may at least produce a marked improvement. (3) Endocrine aberrations. ( 4) Cervical stenosis in some cases. General supportive measures may be instituted next. It is of course sensible Before I proceed let me stress that the that if the patient is grossly over or un­ physician's first concern must be to do der weight this should be corrected, and no harm. In most cases this is an annoy­ any anemia or other chronic debilitating j ing but not a dangerous disorder and it disease must be treated. The patient must not be turned into the latter. Habit should be encouraged to take regular ex­ forming drugs must never be used to re­ ercise, preferably outdoor sports if this lieve the pain and endocrines must be used is possible, and to remain up and around only where there is a definite indication during her menstrual period unless the and then used with discretion. pain is very severe. It is a mistake to advise her to remain in bed at the least suggestion of discomfort. It is known ( 1) Relief at the Time of the Attack that mild exercise tends to relieve the cramps and it certainly helps to keep the This is usually easily obtained. The patient's attention from centering on the simplest remedies should be tried first, pain. The Billig exercises have been espe­ including hot baths, local heat to the ab­ cially designed for the patient who is un­ domen, and non-habit forming analgesics able to get regular exercise in any other such as aspirin or phenacetin. If the lat­ way. I will not describe them here but ter are not strong enough, codeine may a good discussion can be found in the be used. There are many commercial text "Medical Tf'eatment in Obstetf'ics and remedies on the market, containing some Gynecology" , by C. F. Flubmann. Though or all of the following ingredients: none of these things can be classed as aspirin, phenacetin, codeine, phenobar­ definite treatment, they will be found to bitol and dexedrine. Daprysol is one help many patients whose symptoms are good example of these, containing anal­ not too severe. Whether the results are gesics, dexedrine and phenobarbitol. The purely due to psychogenic factors is a dexedrine relieves much of the associated debatable point which I shall not attempt depression despite being partially neu­ to answer. tralized by the phenobarbitol. May I stress again that habit forming drugs such Dilatation of the cervix bas been re­ as morphine or alcohol should never be ferred to before in this article. It is con­ used, even though the severity of the sidered by some to have great usefulness pain may at times seem to call for them. in instances in which the above treatments

114 u.w.o. MEDICAL JOURNAL have failed to produce any reDllSSlOn of but the physician will never know which symptoms. As long as the operator does drug effected the cure, he will be put­ not tear the cervix in any way this may ting the patient to unnecessary expense, be a good treatment. A single dilatation and he will be exposing her to the un­ of the cervix followed by packing in the desirable side effects of all the drugs uterus for three to four days mav be suf­ when one would have been sufficient. ficient. Some recommend dilatation with Hagar dilators, repeated at three day in­ The endocrine preparation in com­ monest use perhaps is dessicated thyroid te~ v als for ten days before the period, th1s treatment to be repeated on three extract. It has been found that a con­ successive months. This treatment is rare­ si derable number of patients with severe ly permanent, though it may be in some dysmenorrhoea have a low B.M.R., but even if the B.M.R. is normal it has been instances and so is worth an attempt. In most cases it will alleviate the symptoms observed empirically that thyroid extract for several months, which may be highly is often helpful. It can be given in the desirable from a psychological point of following dosage: Yr1 gr. b.i.d. for a few view. By breaking the cycle of pain each ~ays , increasing gradually to 2 gr. b.i.d. month it will relieve much of the patient's 1f necessary. A definite systemic response apprehension. to the thyroid extract indicates that the optimum dosage has been reached, this There is one further surgical treatment d~s~ to be decided for each patient in­ which should be used only as a last resort. d1v1dually. This treatment may be con­ If all the other methods of treatment tinued for two to three months, but not have failed and the patient is in such indefinitely. severe pain each month that something The other commonly used endocrine obviously must be done about it, then preparation is some form of estrogen. this surgical procedure may be used. The It must be stated that estrogens should procedure I refer to is a presacral neurec­ not be used routinely but only if an un­ tomy. This is quite effective when it is derdeveloped uterus can be definitely done and there are few undesirable after­ demonstrated. It can sometimes be of effects. It must be remembered that the considerable help in these cases and sensory nerves to the bladder have also should be given in the first half of the been cut and the patient should be warned menstrual cycle. Small doses are used not to wait for painful sensations before in the hope of stimulating growth of the emptying her bladder. A complete loss underdeveloped uterus but larger doses of bladder control is a rare sequel to this are used to stop ovulation and so produce operation. It must also be remembered, a painless period. There are several prepar­ however, that this is a major abdominal ations of estrogen which can be used. operation and so not to be undertaken Some of the commoner ones are: without adequate indication. (1) Diethylstilboestrol, which is given (3) Endocrine Therapy in the dosage of 1 mgm. per day for the first fifteen days of the This is the newest form of treatment. cycle. Almost all the endocrine preparations have been tried at one time or another (2) Estradiol benzoate, which is given but there are only two in general use at as 1.66 mgm. I.M. beginning on the present time and one other which is the sixth day of the cycle and re­ used occasionally. Shot-gun therapy with peated every three days for six two or more of these drugs at one time doses. is most undesirable. The patient may re­ ( 3) Estinyl and premarin are possible ceive some benefit from such treatment oral preparations.

NoVEMBER, 1955 115 ---Dysmeno"hea:------

The above dosages are those required to of dysmenorrhoea, particularly the pri­ stop ovulation. There are of course many mary type, and the essential simplicity of variations of the above treatment as to its management if the physician keeps details of dosage and time of adminis­ the probable etiology in his mind at all tration, but the above are quoted as ex­ times and takes as his primary rule that amples. There are side effects such as he will do no harm to the patient. He nausea and vomiting and abdominal pain, must start with the simpler forms of and there are unwanted after-effects such management, he must use estrogen only as a profuse flow during the period after if there is definite evidence of under­ that in which treatment was used. Estro­ development of the uterus, and he must gen must never be administered contin­ reserve the surgical treatment for severe uously but only for two or three consecu­ cases refractory to all other measures. tive periods. The treatment is purely tem­ If these general principles are remem­ porary and the pain begins again when bered and followed, the practitioner should it is discontinued, but the relief for sev­ have a large percentage of successes in eral months will be a boon to the patient the treatment of dysmenorrhoea. and if there was a large psychogenic aspect there is again the chance of curing the patient by breaking the cycle. The estrogen also stimulates the under-devel­ BIBLIOGRAPHY oped uterus and so may on occasion effect a permanent cure in this manner. Textbook of Gynecology, Novak and Novak, fourth edition, 1952. The Williams and .I Wilkins Co., Baltimore. Testosterone propionate and progester­ one have both been used in the past and A Textbook of Gynecology, James Young, sixth edition, 1944. Adam and Charles are occasionally used now. These are quite Black, London. costly and again only temporary, so there Office Gynecology, J. P. Greenhill, sixth edi­ is little need to use them in preference tion, 1954. Year Book Publishers, Chicago. to estrogen. Textbook of Gynecology, A. H. Curtis and ]. W . Huffman, sixth edition, 1950. W . B. Saunders Co., Philadelphia and j Summary London. In this article I have attempted to bring Medical Treatment in Obstetrics and Gynecol­ ogy, C. F. Fluhmann, 1951. The Williams to the reader's attention the importance and Wilkins Co ., Baltimore.

116 U.W.O. MEDICAL JoURNAL Diagnostic Quiz

Don Bondy, Meds '56

Many Journals feature quizzes of this hypogastric pain. She had been vomiting nature but rarely are they devoted entirely since the onset of the pain. Palpation of to Gynecological disorders. the abdomen revealed a definite round tender swelling in the hypogastrium. This We have selected six classical cases and swelling was also palpable by vaginal presented the minimum essential clinical examination. evidence required for a diagnosis. The diagnoses are printed at the bottom of the page. CASE #5- A 26 year white female, in her six­ CASE #1- teenth week of her second pregnancy, A 28 year white female, three months complains of a sudden abdominal pain pregnant, presents herself complaining of and vomiting. Her abdomen is tender hypogastric pain, nausea and urinary re­ and swollen. She also complains of ver­ tention. Examination revealed a hypo­ tigo and faintness. Physical examination gastric swelling larger than that com­ also shows the presence of free fluid in patible with a three-month pregnancy. the abdomen and tenderness on digital Catheterization failed to reduce this pressure over the pouch of Douglas. Serial swelling. haemoglobin determinations show a rap­ idly progressing anemia. Further ques­ CASE #2- tioning revealed that she had baa some· "spotting" for the past two weeks. A 32 year white female in the 16th week of her first pregnancy phones her obsetrician complaining of lumbar back­ CASE #6-- ache, hypogastric pain and slight uterine A "68 year white female, who is under­ bleeding. weight and in state of poor nourishment complains of a bloody, foul smelling dis­ CASE #3-- charge. Examination and culture of this A 24 year white female, four months discharge failed to reveal Trichomonas pregnant, complains of a sudden rise in organisms. Vaginal smear, using the temperature (103 degrees), rigors and a Panpanicoleou technique, was negative. feeling of chilliness, and abdominal pain. Examination revealed her to have ten­ derness in the right loin under the costal ANSWERS TO DIAGNOSTIC QUIZ- margin, costovertebral tenderness on the right side. Urinalysis showed turbidity, 1. Retroverted uterus. albuminuria, pus cells and on culture 2. Threatened Abortion. E. coli. 3. Pyelitis. CASE #4- 4. Ovarian Cyst with twisted pedicle A 19 year white female is admitted to 5. Rupture of Tubal Pregnancy. hospital with a sudden acute attack of 6. Carcinoma of Cervix (endocervix).

NOVEMBER, 1955 117 Amenorrhea Ellen Martin, Meds '56

INTRODUCTION Amenorrhoea is a symptom only and indicates some interference with the menstrual cycle. The diagnostic problem is to determine at which site the inter­ ference occurs. The normal cycle depends upon the harmonious correlation of the hormonal function of the anterior pituitary and of the ovary, and the uterus, any defect either functional or structural of these organs will cause amenorrhoea. It is important to consider the role of the hypothalamus in the control of the pitUitary, and . also the interrelationship of all the endocrine organs, because a defect in one, may secondarily affect the others.

Amenorrhoea is by definition the ab­ -small adult type of sence of menstruation for one or more uterus periods between puberty and menopause. -destruction of both ovaries It is not a disease but merely a symp· (b) Circulatory system tom. It may be primary, in which case -anemia menstruation has never occurred or it may -leukemia be secondary, in which case menstruation -Hodgkin's disease has been established and then arrested due to a variety of causes. A classifica­ (c) Wasting diseases tion according to etiology is very helpful. -malignant growths -tuberculosis -prolonged suppura- Oassification of Amenorrhoea tion I. Apparent: -diabetes -late stages of 1. Congenital nephritis -imperforate vagina -absence of vagina (d) Toxic -imperforate cervix -after specific fevers -<:hronic poisoning 2. Acquired from lead, mercury (a) Closure of vagina morphine -due to specific fevers (e) Diet -due to injury -alcohol (b) Closure of cervix -ketogenic diet -due to injury (f) Altered Internal Secretion -following operations -anterior pituitary disturbances; pan­ II. Real: hyopituitarism; chro­ I. Physiological mophobe, acidophilic, (a) During pregnancy basophilic adenoma (b) During lactation -myxedema 2. Pathological -Exopthalmic goitre (a) Generative System -Addison's Disease -absence of essential -obesity organs -

118 u.w.o. MEDICAL JOURNAL 1 (g) Nervous System formation of the genital organs, disease -various forms of or disturbance of nuitrition or disturb­ insanity ances of the endocrine system. -cold just before the The next step in the differential diag­ onset of flow, or dur­ nosis is to determine if amenorrhoea is ing flow apparent or real. In apparent amenorrhoea, -suggestion (fear of there is an absence of external bleeding pregnancy) but the menstrual cycle is normal there -Anorexia nervosa being some form of obstruction or me­ Such a classification is useful in the chanical abnormality of the genital tract. assessment of the patient whose presenting If this condition continues, haematocolpos and often only complaint is amenorrhoea. and haematosalpinx may occur. There is Investigation usually a history of periodic cyclic dis­ comfort similar to that experienced with History-The diagnosis of the cause may normal menstruation but without external occasionally be made on the basis of his­ bleeding. As time goes on, and the blood tory alone. In primary amenorrhoea some continues to accumulate behind the ob­ constitutional or congenital abnormality struction, the pain may become almost should be sought for. Injuries at birth and continuous due to the accumulation of childhood illnesses should be noted. The blood in the uterus, tubes and occasion­ patient should be questioned about the ally the peritoneal cavity. onset of menstruation and cycles of the other members of her own family. The causes of this condition may be In secondary amenorrhoea, one should congenital or acquired. Congenital causes investigate the mode and the time of onset include congenital absence and imperfor­ of menses, psychological effects of men­ ate vagina, imperforate hymen and im­ struation, changes in environment and perforate cervix and double uterus with emotional disturbances which may have retention. Acquired causes may be due some effect on the menstrual cycle. For­ to closure of the vagina or cervix from mer diseases and chronic dehabilitating injury following surgery or specific fevers. illnesses are also important. Vaginal examination of these cases will reveal an obstruction above where one Physical Examination-The physical ex­ usually feels the distended vagina or amination should include: (a) a complete uterus. Of course in the case of imper­ physical, at which time general body forate hymen no vaginal examination is build, hair distribution, secondary sex possible, but the hymen may be dis­ characteristics should be noted; (b) a tended and bulging with blood. Rectal pelvic examination. examination may give some indication of Special Examinations-special techniques the volume of blood behind the obstruc­ which may be useful are endometrial bi­ tion. In severe cases a mass is easily pal­ opsy, X-ray of the sella tursica, basal pated abdominally. The treatment in these metabolic rate, and if indicated, hormone cases is the relief of the obstruction by analysis of the blood and urine. appropriate surgery. Differential Diagnosis Real Amenorrhoea The physician's first concern, when a (1) Physiological Ca~~ses patient presents with amenorrhoea, is to Real amenorrhoea will now be con­ determine if it is primary or secondary. sidered. Real amenorrhoea may be either This can usually be determined by an physiological or pathological. Physiologi­ accurate history. Primary amenorrhoea cal causes are by far the most common may be due to congenital absence or mal- causes.

NovEMBER, 1955 119 ---Amenorrhe·~------

By definition, amenorrhoea is the ab­ rare but may occur. Peritonitis in sence of menstruation for one or more childhood may destroy ovarian tissue, periods between puberty and the meno­ leading to non-functioning of the pause, so we have already excluded ovary. In adult women follicular amenorrhoea which occurs before the cysts may cause short periods of onset of puberty and that which occurs amenorrhoea, as may also corpus lu­ after the menopause. However, after the teum cysts. Sclerotic disease of the menopause has onsetted, there may be ovary in W'hich there is increased scanty, irregular periods for a time before fibrosis of the ovaries is believed the complete cessation of menstruation. occasionally to cause amenorrhoea by Pregnancy should always be excluded by decreasing estrogen formation. the usual and routine obstetrical exami­ Tumours of the ovary which cause nations. During lactation there is usually destruction of both ovaries may rare­ no external manifestations of the men­ ly cause amenorrhoea. The arrheno­ strual cycle, although ovulation does occur blastoma, by production of andro­ during the period of lactation without the genic hormone arrests follicular ma­ resumption of the menstrual flow. turation, ovulation and luteum for­ (2) Pathological Ca~~ses mation and leads to cessation of The pathological causes of amenorrhoea menstruation. Inflammatory disease are diverse and require special attention. of the pelvis, and irradiation also (a) Pathology of Generative System: destroy ovarian tissue and amenor­ The uterus may be congenitally ab­ rhoea ensues. Of unknown cause is sent, hypoplastic or refractory to the a premature aplasia of the ovaries stimulation of the sex hormones. Con­ which in essence is an early meno­ genital absence of the uterus is a rare pause. The aplasia of the ovaries is anomaly, but hysterectomy is becom­ unaffected by pituitary stimulation. ing quite common and has been over­ This occurs in the menopause also. looked in the past as a cause of In both. gonadotrophic hormone is amenorrhoea. Hypoplasia of the uter­ up and the hypophysis becomes us may be either a primary or a hyperplastic. secondary cause. Uterine hypoplasia, (b) Systemic Disorders: when causing a primary amenorrhoea, Amenorrhoea may occur in con­ is usually the result of decreased junction with other diseases. Vari­ ovarian and pituitary function. In ous wasting diseases and circulatory this case the signs of hypopituitrism disorders which are commonly asso­ are also present. Sometimes uterine ciated with amenorrhoea are listed hypoplasia is associated with small in the classification above. Dietetic external genitalia, but the breasts, and toxic factors may be concerned. secondary sex characteristics, and Protein and the B vitamins are neces­ growth are usually normal. It is also sary for the proper function of the of interest that in some, excretion of pituitary. gonadotrophic hormones and estrogen is normal. This suggests that the (c) Pathology of the Endocrine Glands: genital duct system may be refrac­ (i) Anterior Pituitary- tory to hormonal stimulus. Second­ The anterior pituitary contains ary amenorrhoea due to uterine hypo­ three types of cells. The chromo­ plasia can usually be corrected by phobes do not produce any known estrogen, although untreated cases of hormone. The acidophils produce long standing may be refractory. growth hormone and the basophils Congenital absence of the ovary is produce gonadotrophins.

120 U.W.Q. MEDICAL JOURNAL Panhypopituitrism is a state in 17-ketosteroid values fall to almost which all the gland is underfunction­ zero. However, ovarian function may ing. There is consequently inadequate be normal until debility is so great stimulation of the ovaries and con­ that pituitary function is disturbed. sequent amenorrhoea. Here the gen­ Amenorrhoea in these patients often eral appearance of the patient will disappears when malnutrition is cor­ point to the diagnosis. 17-ketosteroid rected by adrenal cortical hormone estimation in these cases is practically replacement. zero. Included in this group of dis­ (iii) Thyroid- eases are Simmond's disease, pituitary Both hypothyroidism and hyper­ dwarfism and Sheehan's syndrome. thyroidism may lead to amenorrhoea. Sheehan's syndrome may follow dif­ The hypothyroid amenorrhoea is ficult delivery, especially if there has thought to be due to poor cellular been severe post partum hemorrhage. activity of the whole body, including It is believed to be caused by ischemia the cells of the pituitary and ovary. of the pituitary due to thrombosis of In hyperthyroidism amenorrhoea may its vessels. Destruction of 75 % of be caused by toxemia which also the gland causes moderate symptoms affects the ovaries. In some cases according to Sheehan. the amenorrhoea is attributed to Chromophobe adenomas and cra­ rapid excretion of estrogens which niopharyngioma may cause hypo­ prevents its concentration in the pituitrism by pressure on the other uterine mucosa, thereby effecting cells of the pituitary. X-rays of the amenorrhoea. sella-tursica are helpful in diagnosis. If a tumour of the acidophilic cells is Functional Amenorrhoea large enough to cause considerable It has been suggested that sixty percent destruction of the pituitary, ovarian of cases of amenorrhoea are functional. function may cease with amenorrhoea of these cases fifty percent are also obese. following. The signs and symptoms This suggests that the hypothalamus may in an acidophilic tumour are those be involved in this problem. Psychological of acromegaly. stimulus may affect the hypothalamus di­ Basophil tumours result in Cush­ rectly from the cerebral cortex. It is known ing's syndrome with amenorrhoea. that shock, anxiety, sexual disharmony, They present a picture similar to depression, change in occupation or change those with adrenal tumour, which in environment cause menstrual disorders, will be mentioned later. but the exact mechanism is unknown. Lesions of the hypothalamic area Anorexia nervosa represents a severe may upset pituitary function, leading reaction to trauma. It generally occurs to dystrophia adiposo-genitalis (Froeh­ in adolescent girls. Extreme wasting and lick's syndrome). There is genital emanciation may occur. These cases must hypoplasia, amenorrhoea and a girdle not be confused with Simmond's disease, type of obesity. which is usually a disease of older wom­ (ii) Adrenal Cortex- en, onsetting after a pregnancy. In ano­ In hyperplasia and tumours of rexia nervosa, there is no breast atrophy, the adrenal cortex there is increased no loss of pubic or axillary hair and production of adrenal androgens. there is no decrease in the urinary level This leads to virilism and amenor­ of 17-ketosteroids. rhoea. 17-ketosteroid excretion is The treatment of functional amenor­ high. In Addison's disease the adrenal rhoea is to determine the abnormal psy­ hormone production is decreased and chological stimulus and eliminate it. How-

NOVEMBER, 1955 121 ---Amenorrhea------

ever, this often requires a prolonged per­ should always be determined. Treatment iod of psychotherapy. The practitioner should not be too long delayed because should be on the lookout for this type certain cases become refractory to treat­ since they make up a large proportion of ment if neglected too long. The aim is all cases of amenorrhoea. to treat the underlying disease wherever Conclusion possible rather than merely symptomatic The underlying cause of amenorrhoea treatment.

SOME PROBLEMS OF CURRENT The figures show that the recovery rate INTEREST RELATING TO in Stage I is 62.5 % at institutions in CLASSIFICATION AND TREATMENT favour of primary surgery, and 65.3% at OF UfERINE CARCINOMA tho.se in favour of primary radiotherapy. James Heyman, M.D., Stockholm, Sweden. However, the value of radiotherapy is American Journal of Obstetrics and Gyn­ ascertained by statistical proof, whereas ecology, March, 1955. conclusive evidence of the value of pri­ Heyman states at the outset that the mary surgary is not yet available. The value of different methods of treatment author feels that there is no urgent need can be established only by comparing re­ for primary surgery in cervical carcinoma sults presented in uniform and compar­ in centres where adequate radiotherapy is able therapeutic statistics. Uniformity of available. statistics requires precise definitions on Carcinoma of the Corpus the varieties of the disease. The two con­ Classification: ventional groups are carcinoma of the For clinical purposes only two stages cervix and carcinoma of the corpus. He are used: Stage I to include cases in which believes that it is not justifiable to com­ the growth is confined to the uterus, and pare statistics based on the surgeon's Stage II to include cases in which the classificaion against those cases based on growth has spread outside the uterus. clinical classification. Treatment : Carcinoma of the Cervix Heyman states that in the treatment Classification: one must choose among three methods: Stage 0 must be more precisely defined. (1) hysterectomy plus post-operative ir­ Treatment: radiation; (2) preoperative intracavitary lntracavitory radium applications at radium followed by hysterectomy; (3) present is the most effective treatment in primary intracavitary radium followed by the control of cervical carcinoma. Sur­ hysterectomy in cases of failure. gery is used in cases of failure or local Five Year Results: recurrence following radiotherapy. hysterectomy and post-operative radia­ Five Year Recovery Rate: tion-73.5%. (1936-1948 at Radium liemmet) pre-operative radium and hysterectomy Total number of cases treated-3704. -70.0%. Relative Recovery Rate--42.2%. primary radiotherapy-65.5%. Stage I -12.2% total number cases; These figures indicate that hysterec­ recovery 71.0%. tomy followed by post-operative radium Stage II -51.4% total number cases; is the best treatment, but this series was recovery 50.3%. done on a selected number of cases. The Stage 111-28.1% total number cases; author believes that primary radiotherapy recovery 24.7%. is justifiable where the operators are well Stage IV- 8.3% total number cases; qualified. recovery 9.1%. -Robin Waite, Meds '56

122 U.W.Q. MEDICAL JOURNAL Recent Acquisitions m the Library The library of the University of W estern Ontario contains approximately 49,000 volumes, all fully catalogued, and is regarded as one of the best working collections of its kind in Canada. It is particularly rich in complete files of the more important medical journals. The total number of titles of periodicals, complete or incomplete is nearly 2200, while 740 periodicals and 71 annuals are recej,yed currently. All the books are on open shelves and the students have access to all books and current periodicals. Recent aquisitions by the library are placed on the new­ book shelves where they are left for staff and student appraisal and considera­ tion. Of these new books, we have selected the most recent and the most outstanding for your immediate attention. BOTANY Fisher, J. T.: A few buttons missing. Eigsti, 0. J.: Colchicine in agriculture, 1951. medicine, biology, and chemistry. Major, R. H.: A history of medicine. 1955. 1954. GYNECOLOGY AND OBSTETRICS NATURAL IDSTORY Burch, J. C. : Hysterectomy. 1954. Baq, Z. M.: Fundamentals of radio­ Fish, J. S. : Hemorrhage of late preg­ biology. 1955. nancy. 1955. Lea, D. E.: Actions of radiations on Gray, L. A.: Vaginal hysterectomy. 1955. living cells. 1955. Greenhill, J. B.: Obstetrics in general Rashevsky, N .: Mathematical biophysics. practice. 1948. 1948. Smout, C. F. V.: Gynaecological and ob­ Boell, E. J. (ed.): Dynamics of growth stetrical anatomy and functional his­ processes. 1954. tology. 1953. Stacy, R. W .: Essentials of biological and Titus, P.: The management of obstetric medical physics. 1955. difficulties. 1955. OTORHINOLARYNGOLOGY Ullery, J. C. : Stress incontinence in the Morrison, W. W.: Diseases of the ear, female. 1953. nose and throat. 1955. PATHOLOGY INI'ERNAL MEDIONE Color atlas of pathology v. 2. 1954. Cecil, R. L. F.: Textbook of medicine. Trumper, M.: Oinical biochemistry. 1955. 1955. PHARMACY English, 0 . S.: Emotional problems of Smith, T . J. and Nephew, Ltd.: Elasto­ living. 1955. plast technique. 1950. Gibbons, R. J.: Chronic alcoholism and PHYSIOLOGY alcohol addiction. 1953. Elliott, K. A. C. : Neurochemistry. 1955. Hoch, P. H. : Psychiatry and the law. Turner, C. D.: General endocrinology. 1955. 1955. Master, A. M. : Cardiac emergencies and SURGERY heart failure. 1955. Boyd, W.: Pathology for the surgeon. O'Neill, D.: Modern trends in psychoso­ 1955. matic medicine. 195 5. Hale, D. E.: Anesthesiology. 1954. Pullen, R. L. R. : Pulmonary diseases. Meigs, J. V.: Surgical treatment of cancer 1955. of the cervix. 1955. Wakefield, E. G. : Clinical diagnosis. Watson-Jones, R.: Fractures and joint 1955. injuries v. 2. 1955. Whitaker, C. A.: The roots of psycho­ THERAPEUTICS PHARMACOLOGY therapy. 1953. Lodge, T.: Recent advances in radiology. MEDIONE (GENERAL) 1955. Bryan, J. E.: Public relations in medical Wright, H. N . G.: Textbook of pharma­ practice. 1954. cology and therapeutics. 1955.

NovEMBER, 1955 123 UNIVEllSITY OP WESTE.RN ONTAlliO MEDICAL JOUllNAL

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