4. Dysmenorrhcea membranosa. This is a somewhat rare form of dysinenor rh(ma, but one which has long been recog nized, and is described by all writers of gynrecological treatises.
During tett years' experience, ease of znembranous clysmenorrlima never met with. The spasmodic-neuralgie form without any pathological lesion is also extremely rare. The worst eases are usually due to anteflexion. Dilatation gives relief, but must be repeated. There is not any scientific proof that the ovary prr se ever caused dysinenorrlitea. When no lesion can be fottnd the fattlt is in the nervous system, and to this the at tention must be directed. Fibroma not infrequently causes dysmenorrlicea, even in women under 30. The tumor may be very small and escape notice, unless a careful examination is made under an a.laesthetic. Parsons (Brit. Med. Jour., Oct. 24, '97).
Dysmenorrhcea membranosa is due to an hypertrophied condition of the endo metrial decidua; that is, of the exfolia tive portion of the uterine mucous mem brane which is shed at each menstrual epoch. This membrane varies in thick ness and density in extreme instances, showing a perfect cast of the cavity of the uterus.
Separation of the membrane frona its underlying attachment and its expulsion from the uterus mean an unusual amount of uterine work and severe pain as an almost constant accompaniment. It usually occurs, too, in women whose nutrition is defective, and is conse quently a matter of more serious impor tance than if it were among the robust and well nourished. It is, of course, a form of obstructive dysmenorrhcca, but its peculiarities are so marked that it may be well to continue to consider it a dis tinct variety.
Etiology and Pathology.—Anything which prevents or disturbs the equilib rium of the normal conditions described will cause dysmenorrlicea. It is of ex ceedingly frequent occurrence. It is a matter of great surprise that so many women should present this symptom, which appears with. some of them at the advent of puberty and continues with varying intensity until the termination of menstrual life, while with others it disappears with pregnancy, with the physical changes attending mature life, or as the result of surgical treatment.
That it should occur so frequently, and especially in communities in which the highest intellectual development has been reached, is not a flattering com mentary upon the results of modern civilization. Still, this is counterbal anced by the fact that dysmenorrhcea is usually curable by judicious and appro priate surgical means.
A thorough revision of our views on this subject has become necessary. in thc light of recent experience. More than 75 per cent. of the cases of painful men struation are not dependent upon ana tomical effuses. The pain is really due to tetanic contraction of the circular muscle at the os internum, such as oc curs in other sphincter-muscles in neu rotic subjects. Me»ge's theory that dysmenorrin»a is due simply to an ex aggeration of the contractions of the longitudinal muscular fibres, which al ways accompany normal menstruation, does not hold, for, if the symptoms were due purely to mechanical obstruction, it should invariably disappear after child birth, which is not the case in nervous and hysterical women. Uterine colic cannot be due only- to the passage of clots, since in many typical cases of dysmenorrhoea there is a free escape of fluid blood. Moreover, the pains are often most severe from twelve to twenty-four hours before the flow ap pears, instead of on the second or third day, when it is most profuse and clots usually appear. Theilhaber (Cearalb. f. Gynilk., No. 3, 1902).
"Women in the savage or barbarous state and women who are constantly en gaged in out-of-door labor are seldom sufferers from this cause, though their pelvic organs may be defective in struct ure and though they may habitually be subject to experiences which would un failingly cause dysmenorrhcea or even complete suppression of the menstrual function in women of less robust organ ization. This is, in part, owed to the in creased power of resistance to physical ills which is favored by an out-of-door life, and, in part, to the greater tiveness to pain of women in the lower strata of social and intellectual develop ment.