164: DISEASES OP THE UTERUS. 



a menstrual congestion of extraordinary activity might give rise to 

 pain in the womb and ovaries, by irritating the nerves of those or- 

 gans (congestive dysmenorrhcea). In other cases we are reduced to 

 assuming that an unnatural irritability of the nerves either gen- 

 eral and combined with hysteria, or else local and limited to the gen- 

 ital region is the cause of the suffering (nervous dysmenorrho3a). 

 But there is no doubt that we more often have to do with organic 

 disease of the womb or ovaries or other pelvic organs, or with a 

 fibromyoma, an infarction, a dislocation, or a degeneration of the 

 ovaries. One form of dysmenorrhceal pain proceeds from spasmodic 

 contractions which the womb sets up in order to expel some foreign 

 body from its cavity a polypus, a blood-clot, or a collection of 

 liquid blood. The obstacles to the menstrual outflow are stricture 

 of the cervical canal, either congenital or acquired, acute flexion of 

 the womb, and growths blocking up the channel ; perhaps also spasm 

 of the internal os (obstructive dysmenorrho3a). In this form the 

 pains present a characteristic intermitting type, like those of colic 

 or like labor-pains, the spasms corresponding with the periods of 

 uterine contraction (uterine colic); and these attacks, which are 

 more severe before the flow begins, subside after the contractions 

 have expelled the stagnant blood from the uterine cavity. 



Membranous dysmenorrhoea is a special form of obstructive 

 dysmenorrhcea. Under normal conditions at the period of deni- 

 dation, the outer layers of the proliferating mucous lining of the 

 womb undergo fatty degeneration, and are cast off impercepti- 

 bly and in minute particles. Sometimes, however, by a morbid 

 exaggeration of this process, there arises an exfoliation more or less 

 profound of the mucous membrane, which then comes away in 

 sheets. Indeed, the entire menstrual decidua may be cast off, in the 

 form of a complete three-cornered sac corresponding to the form of 

 the uterine cavity, with its smooth inner surface riddled by holes 

 (mouths of the uterine glands), and its outer surface rough and rag- 

 ged. Microscopic examination of the connective tissue of the mu- 

 cous membrane, and the finding of the glands embedded in it, will 

 prevent confusion of such an object with a mere fibrinous clot ; 

 while the more difficult distinction between this process and that of 

 an early abortion will be aided by the circumstance that the expulsion 

 of menstrual decidua is seldom confined to a single menstruation, 

 but is often repeated for months and years, even up to the climac- 

 teric period. 



The chronic metritis and endometritis which often accompany 

 this form of exfoliative menstruation are regarded by many as the 

 cause of the process. The affection is attended by colic of greater 



