DYSMENORRHEA and OOPHORITIS being THISIS FOR THE EDINBURGH UNIVERSITY M.D. DEGREE. By J. OSBORNE CLOSS, M.B., C.M., Edin. f+^LIBRARYj-H Mills, Dick & Co., General Printers, Octagon, Dunedin. 1 8 9 2. <0l c J*> Y- r y ^*t-JL /Z£- f^y*yCy£.. dSC^g^y. i»< C^-yC-J ^Ly^t~C<-^~ <1^*^ ^OCy/~ %£<f^y-*>—+> * etg t^L. begItothatstate To... <Z£srC/£~ litiliiiw Ml)iliHiVuW EDMoMM l^eZtO-C^L- X^<7rZsTUfC ~~£^JL cr^ t^ufT In &&£2srV toreplyyour ^VovnA071, geatt%of letterof.. ~t%L <y<UdZ fci / Fromthe Jfatnltgof y*ru_cm /<ff£ JUfriatu. ^Trtsyr^t^a^cxz^9iy^Cco~~&VLtmtmT&C 9rL^-^^<j^jvstuytl&T ~h^Lt\7l^frCcHs£f>lstF6?1s/L4msC&- DYSMENORRHEA and OOPHORITIS being THB5IS FOR THE EDINBURGH UNIVERSITY I.D. DEGREE. By J. OSBORNE CLOSS, M.B., C.M., Edin. Mills, Dick & Co., General Printers, Octagon, Dcnedin. 18 9 2. Dysmenorrhea & Oophoritis. While I recognise that it is a good thing for clinical purposes and for convenience to differentiate dysmenorrhea into certain classes, according as near as possible to its cause, yet I am of opinion that so closely are the ovaries, tubes, and uterus related to each other during the menstrual act, that none of these organs can be considered as envolved to the perfect immunity of the others. Therefore, in treating of the subject as set forth above, I prefer to take the term dysmenorrhea, without holding to any distinct classification, whatever may be the cause, or wherever the seat of pain. It is, however, principally my object to set forth in these pages, as far as possible, the relation between dysmenorrhea and inflammatory changes in the ovaries in cases that have come directly under my observation and treatment. If dysmenorrhea were a disease, associated with the uterus alone, one would naturally suppose that, as that organ is easily within reach and treatment, such a painful affection would speedily succumb to the remedy ; but how often is it otherwise ! How often is the treatment of the disease, indicated by this painful symptom, undertaken with but little hope of success! From the very fact that the cause is frequently unknown or only guessed at, or again if it be known, it is sometimes situated beyond all palliative measures, and operative interferences, often •of a very serious character, are resorted to. I admit that in cases of os atresia, and in flexions of the uterus, minor operative treatment does a deal of good, specially so if done in time; but even these minor operative treasures are often fraught with danger to the patient from inflammatory mischief that may ensue in the pelvic cellular tissue, or peritoneum and adjacent organs, in which case the dysmenorrhea 4 DYSTTENOEBHCEA AND OOPHOEITIS. Trill be worse than ever. True, there are many successes due to the use of the metrotome or treatment of flexions in suitable cases, but, as I have just said, it will much depend not only on the way in which the treatment is applied, but, what is of equal importance, the time at which it is done. To my mind, as soon as either os atresia, or some flexion of the uterus, is diagnosed to be the cause of the dysmenorrhcea, or if only an important factor in that cause, immediate operative- interference is imperative, and if undertaken with all due precautions is very likely to give gratifying results. But, frequently, from delicacy or some other like reason, this treatment is deferred, and perhaps after months or years of suffering the operation is at last undertaken, but is proved from the continuance of the dysmenorrhcea to have been done " too- late in the day." I am persuaded that it is this delay in taking decided action that accounts for much, if not all, of the marked pathological changes that are found in the tubes and ovaries of cases with this history. My experience is that dysmenorrhcea indicates an abnormal condition of affairs not to be lightly treated, specially so in young girls and married, nullipara, which, if continued and neglected, the ovaries and tubes are the organs that will after¬ wards tell the tale. I do not for a moment wish to convey the idea that I think os atresia, flexions, and exfoliation of the uterine- mucus membrane are the sole causes of dysmenorrhcea, although they do seem to account for many cases; for there can be no doubt but that after these mechanical obstructions are removed,, menstruation in many is at least rendered tolerable. One might with very good reason ask, how so ? Tor it is well known that there are many women who have os atresia, or flexions of the- uterus, yet menstruate regularly and suffer no pain. So that one- is driven to seek other reasons for painful menstruation. Naturally,- one turns to the pathologist as much as to the specialist for light on this question, but not with much success. As yet much is shrouded in mystery ; certainly much has been DYSMENORRHCEA AND OOPHORITIS. 5 ■done in the pathology of the ovaries and tubes, but much yet remains to be told as to the causes of dysmenorrhcea. In exfoliation of the uterine mucus membrane there seems to be a well-recognised cause of pain, more especially if compli¬ cated with flexion or narrow os. But why in some cases the uterine mucus membrane should be shed in pieces that are easily recognised by the naked eye, and in others, if shed at all, not recognisable in the menstrual debris, and yet in the latter there may be just as much pain as in the former, although the uterine passage is perfectly patent. The ease, for instance, which Schultze relates—in which the uterine passage and outlet were sufficiently large to admit the free passage of a sound before the menses appeared, and yet the patient was suffering agony—is a good case in point. I cannot say that such an extreme case has ever come under my personal observation, yet I am sure I have had many that closely approach it, which, when the menses have fairly started the acute pain subsided, leaving only a dull heavy feeling as a result of the excessive congestion and severe pain. Such cases must indicate a certain hyperemia of the uterine mucus membrane and the immediate neighbouring organs, with probably some tissue change in the mucus membrane itself— differing from the recognised normal type—whereby the outlet of blood from its surface is hindered, causing the uterus to con¬ tract and engorge itself more and more until the distended vessels rupture and give relief. I have observed in cases of membraneous dysmenorrhoea that I have had in which the shreds and tatters of uterine mucus membrane were clearly visible to the naked eye, and further demonstrated as such under the microscope, in which there was the appearance of a highly congested membrane differing from the normal type, inasmuch as it was thicker, with an abundance of connective tissue, hypertrophied blood vessels and glands, smooth on the free side, without appearance of cilia or epithelium, somewhat ragged and rough on its lately attached surface, with plenty of connective tissue and some muscular fibres, the whole having a highly vascular appearance. 6 DYSMENOKBHCEA AND OOPHORITIS. Iii the cases that have applied to me suffering under this condition, I have invariably used the metrotome, if os atresia were present, and Hegar's dilators in cases of flexion, with careful use of stem pesseries afterwards, till complete patency of canal was established. In suitable cases too, I curetted the interior wall of the uterus, using strict antiseptic precautions ; but I cannot say that this curetting did much good, as portions of membrane were seen at subsequent menstruations; but their exit was facilitated by the patency of the canal, and the dysmenorrhoea was generally much less than formerly. There is one condition about these cases which struck me as somewhat peculiar, and that is the extraordinary rigidity of the internal os, which resists the entrance of the dilators to such a degree that occasionally the muscular fibres tear rather than yield. It is at this point too, where the divergence takes place between the mucus membrane of the cervical canal and that of the body of the uterus. I have thought that it may be probable that here starts some structural divergence from the usual type, such as a greater abundance of connective tissue about the muscular fibres, or some physiological resisting power in the fibres themselves peculiar to such uteri, imparting to the mucus membrane a greater thickness and resisting power (on account of the increase of connective tissue), and, as a consequence of this, delaying the sanguineous exosmosis and generating a greater tendency to spasmodic contractions of the uterus. I am inclined to hold by the theory that the uterine mucus membrane is not shed at each period of menstruation as a normal and natural process, except in regard to its cilia and epithelium; and when mucus membrane is shed entire or in pieces, it is a deviation from the normal type. Very much, I think, of the dysmenorrhoea which seems as yet unknown in its cause might be found in the resisting power, either in the walls of the capillary vessels or in the mucus membrane, to the natural sanguineous exosmosis. If vascular tension be maintained against uterine mucus membrane, it would act on the uterus very much like a foreign body, inducing DYSMENORRHEA AND OOPHORITIS. 7 contractions of the organ. This structural alteration of the mucus membrane from what is recognised as the normal type may in some cases he a natural and physiological condition, while in others it may be due to some misplacement of the organ, or some cause, either local or constitutional, so acting on the mucus membrane as to materially alter it in structure, giving greater resistance to the blood tension, thus causing pain.