2. A pelvic lesion or abnormality may he present and be the cause of the dysmenorrhoea. A common form of pelvic abnormality found in cases of dysmenorrlicea is some failure of development of the uterus. In extreme cases the uterus may be represented by a mere knot of tissue, and these usually prove very intractable; sooner or later the question of removal of the rudimentary uterus or of the ovaries is sure to arise and must be settled on the lines already suggested. Short of this no operative inter ference is likely to do good, and general measures must be relied on. In other cases the uterus is infantile in type, the cervix being fully de veloped, but the body undeveloped. These cases are not very amenable to treatment, but I think they benefit sometimes from curetting and pack ing with gauze. Again, the body of the uterus may be poorly developed and may be acutely anteflexcd on the cervix, which is often narrow and conical. Many of these cases are relieved by dilatation and curettage; in some I have got good results from Dudley's operation, in which the posterior lip of the cervix is split up, and by the excision of a half-diamond shaped piece on each side and subsequent transvense suturing the external os and cervical canal are brought into line with the axis of the uterine cavity.
In a number of cases examination reveals a condition of endometritis, either a true chronic inflammation as shown by the discharge of muco pus, or a hyperplasia of the endometrium, sometimes associated with dilatation of the capillaries. The endometritis may be combined with retroversion of the uterus. Such cases are usually benefited by dilata tion and curetting. (See under Endometritis.)
In other cases examination shows the presence of an erosion, often an unsuspected cause of dysmenorrhoea as of other symptoms. In my ex perience the only certain cure for this condition is to slice off the affected cervical mucous membrane much as one shaves off a skin-graft. I have tried various caustics, phenol, formalin, and fuming nitric acid, but with very disappointing results. After shaving off the erosion the upper end of the vagina should be packed with iodoform gauze, and after its removal a daily douche should be given for a week.
In about half the cases of fibroid, dysmenorrhoea is a symptom and may be the only symptom of the presence of the tumour. The pain is, however, usually caused by the excessive loss of blood; clots are formed in the uterine cavity, and cramp-like contractions of the uterus are re quired to expel them. In a number of cases a very small fibroid situated at the internal os has been shown to be the cause of dysmenorrhoea. The remedy is the removal of the fibroid, with or from the uterus. (Sec Uterine Fibroids.) Another type of case is that in which the dysmenorrhoea is a symptom of disease of the ovaries or tubes, usually inflammatory. The amount of pain is no criterion of the extent of the mischief. Many of these cases may be benefited by measures adapted to the relief of the tubal or ovarian congestion. (See Ovaritis, Pyosalpinx, Salpingitis.) In still another type of case there is retroversion with endornetritis. (See under Endometritis and Retroversion.)