as in acute arthritis of rheumatic origin, in gouty attacks, in myalgias, especially lumbago, torticollis and pleurodynia, as well as in sciatica, I have invariably employed the mentho-methyl-oleosalicylate, known as betul-ol. Its peculiarly efficient power of penetration and analgesic properties have stood me in good stead. The following cases indicate the value of these drugs.

CASE I. Mrs. K., a German woman, aged 44 years, was of good health with the exception of rather frequent attacks of acute arthritis of rheumatic origin. She had taken salicylic acid in various. combinations, and had frequently used liniments containing oil of wintergreen-at least, the prescriptions called for ol. gaultheriæ. I modified her diet, prescribed baths and saline laxatives, and ordered her to take one capsule of colchi-sal every hour for one day, one every two hours on the second day and one every four hours for a period of a week. Locally, I ordered betul-ol applied by means of gentle friction for five minutes by the watch, twice daily. In ten days all symptoms disappeared, and for the past five months have not reappeared. In addition to the disappearance of the pain and swelling, she has gained in weight and has improved much in energy and spirit, factors which so often go hand in hand with improvement in lithemic conditions. I have advised her to take one capsule three times daily for one week during each month, to prevent recurrence.

CASE II. Mrs. R., aged 30 years, widow, consulted me for very acute pain in the left side. She had had pleurisy two years before. Examination showed the pain to be located in the muscles; in short, a typical case of myalgia. I prescribed colchi-sal capsules to point of tolerance, and ordered betul-ol to be gently rubbed over the painful area twice daily. The pain disappeared in three days. It had been my practice to strap the chest in these conditions, with great benefit, but a patient otherwise in good health, as a rule, does not like the strips around the chest. I have found the above described procedure a valuable substitute, with the additional value of preventing further attacks.

CASE III.-Miss A. L., aged 19 years, was attacked severely with acute rheumatic fever. Both knees were greatly swollen, and her general condition was very poor. She had a number of successive drenching sweats. Her temperature fluctuated between 101 to 104 degrees F., and at one time threatened to reach a point of hyperpyrexia.

It had been my custom up to the time of this case, to administer salicylate of sodium internally and apply equal parts of oil of wintergreen and olive oil locally to the inflamed joints. In this case, however, I ordered colchi-sal capsules, one every hour for twenty-four hours, and one every three hours thereafter. Locally, I applied betul-ol and olive oil, equal parts, and covered the inflamed joints with lambs' wool over oiled silk. With each capsule. of colchi-sal I ordered a glass of cool vichy to be given, and confined the patient to a milk diet. The case made a rapid, uneventful and uncomplicated recovery.-International Therapeutics, October,

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VOL. XXIII.

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For Texas Medical Journal.

No. 3.

Some Pathological Causes of Dysmenorrhea.*

BY HENRY K. LEAKE, A. M., M. D., DALLAS, TEXAS.

Dysmenorrhea signifies difficult menstruation, not painful menstruation, although both conditions are included in the orthodox definition. Menstruation may be scant and difficult, as in some cases of undeveloped uteri, and not painful, while in others, as in menbranous dysmenorrhea, the flow may be profuse and not difficult, yet exceedingly painful; further examples could be mentioned. A word might be found to express painful menstruation leaving dysmenorrhea to bear its own burdens, which are numerous enough. However, I accept the text-book definition and to limit the discussion of the portion of the subject allotted to me, prefer to speak of some major pathological causes of dysmenorrhea rather than of its varied pathology, for this would involve an almost endless detail unnecessary to carrying out the practical design of the symposium. Nor shall I rely wholly upon the literature, but attempt an outline of the mental process which develops ordinarily in the course of my examinations of patients who present themselves with dysmenorrhea, often in aggravated and rebellious form.

venous.

I assume that the fundamental factor in all varieties of dysmenorrhea is congestion, either normal or abnormal, arterial or It is an essential element of normal menstruation. Without congestion, no menstruation, but ovulation may continue actively. Every twenty-one or twenty-eight days there is recurrent congestion of all the pelvic organs. The ovaries secrete a hormone

*Read before the North Texas Medical Association, at Paris, June 17, 1907.

which, passing into the blood stream, exerts its altruistic stimulation (Campbell) upon the menstrual nerve center whence an impulse is sent chiefly to the pelvic arterial system in which the blood pressure is increased, resulting in rupture of the endometrial capillaries followed by relaxation of the arterial vessels throughout the entire pelvic area. I have employed the words "blood pressure" without positive opinion as to the exact state of the arterial vessels in normal menstruation, whether these are contracted or dilated; for inasmuch as in many patients with dysmenorrhea there is evidence of the former condition of the arteries, not alone in the pelvis, but throughout the body, as dysmenorrhea is not possible without congestion and as the pains are quickly relieved by a vasomotor dilator, such as nitro-glycerine (Mary Putnam Jacobi), it appears that blood pressure here as has been claimed in conditions of shock may not so much vary with the size of the arteries as we are accustomed to recognize. Otherwise, why, in explaining the nature of the shock which these cases of dysmenorrhea so much resemble, should Malcolm protest their contraction while Crile, Mummery and others assert the contrary? If we believe that in shock a preliminary stage of arterial contraction obtains, so also in this certain type of dysmenorrhea wherein just prior to the establishment of the flow the patient has "facial pallor, blueness of the lips, coldness of the extremities and a sense of pelvic engorgement," symptoms promptly relieved by the administration of a good vaso-motor dilator, preferably nitro-glycerine.

The pelvic arterial circulation is abundant, but the veins comparatively are large, numerous, tortuous and without valves (Montgomery contra); the mutual adjustment of the two systems being delicate, and, as it were, set upon a hair trigger which may be sprung by the slightest disturbing causes. Contraction of the arteries combines with a sluggish venous current to produce painful engorgement. Such causes may be cold, fright, anxiety, shock and so forth; a weak and irritable nervous system, congenital or acquired predisposing by its inherent instability, as may be seen in girls at boarding schools or those having sedentary occupations, particularly if deprived of air and sunlight. The normal menstrual congestion-menstruation-now becomes pathological-dysmenorrhea-and when established as it may be in a more or less chronic form, constitutes a special variety of the disease rightly named congestive dysmenorrhea. Under this head also some authors have placed gout and rheumatism, well known causes of sluggish circulation in the abdominal organs and a faulty metabolism

which finds expression in the pelvic area during the normal activity of the organs concerned in menstruation.

Menstrual congestion super-added to the liberal blood supply developed in the growth of pelvic neoplasms favors congestive dysmenorrhea. Uterine and broad ligament fibroids, especially when impacted in the pelvic basin, are examples of this class. The several displacements of the uterus, notably the retroversio flexed organ are familiar instances. Pressure upon the thin-walled veins obstructs the return circulation, entailing engorgement and pelvic pain at the menstrual period. In the pathology of some writers prolapsed ovaries assume so great importance in dysmenorrhea as to justify their frequent removal. In my opinion this deduction is unwarranted. If displaced, enlarged and adherent their removal may be justified, but this is done for inflammation, not for displacement, with attendant congestion. According to Eli Van De Walker, a well known authority on displacements, "The position of the ovaries in the pelvis is a minor matter and unattended by either functional or sensory symptoms; these are due to other pelvic conditions."

Well-developed ovaries may coexist with undeveloped uterus which affords a limited surface for menstruation, the amount of undergrowth varying in different cases, hence difficult and painful flow. I recognize two types: That wherein there is no local nor constitutional disturbance, and another marked by severe dysmenorrhea; the difference owing to the inherent nervous stamina possessed by the former. If treatment avails to perfect development, as claimed by Carstens, by the use of intra-uterine stems, the dysmenorrhea and its accompanying sterility are cured. Lawson Tait made much of this form of dysmenorrhea for which he promptly operated by removing the adnexa; I suspect that his diagnosis ofttimes was intuitive, not logical.

Exceptionally the menstrual flow in congestive dysmenorrhea is copious and attended by small clots throughout the period. This may be witnessed during the first months of menstrual life in some subjects where the endometrial arteries are undeveloped in their muscular coats and easily rupture, or be owing to an harmonic stimulation of the menstrual center disproportionate to the needs of the function, but which probably in time is regulated without resort to the curette, although this instrument may be required finally, especially in the former class of patients.

I attempt not to mention all the existing causes which may derange the equilibrium of the pelvic circulation and so cause conges

tive dysmenorrhea without palpable structural lesions in the pelvis. Such a disturbance is met with most frequently in nulliparous women, but in these and in the parous, while congestion is the primal factor in the causation of pain, the vis resistentia, both of the local and general nervous systems, is essential to its presence, quality and permanence. Therefore, the severity of congestive dysmenorrhea varies with the nervous stability of the individual in whom it occurs-an important point in practice which should not be overlooked.

But the normal harmonic congestion of the pelvis may be augmented by structural change in the pelvic tissues themselves, with or without pain, and so merging, constitute a variety of disease-congestive-inflammatory dysmenorrhea. It is in this field alone, perhaps, where the abdominal operator for dysmenorrhea may find a safe retreat from the shafts of adverse criticism, for in these circumstances it is often required to ablate the diseased structures, or by conservative operations, such as breaking up adhesions and restoring the positions of displaced organs where, by readjusting the circulation, allows them to functionate with painless regularity.

Chronic inflammation, latent or pronounced, at any point in the pelvis, is aggravated by menstrual congestion which may superinduce a so-called recrudescence, as witness adnexal inflammation, chronic metritis, chronic endometritis, or chronic peritonitis with its varied origin and character. As a frequent cause for dysmenor rhea so-called ovaritis is emphasized in modern pathology. Ovaries knobbed, serrated and hardened, large or small ("cirrhotic"), with or without adhesions associated with painful menstruation are assumed to be its cause; chronic inflammation, the pathological factor. This is doubtful. Such ovaries are discovered often when no dysmenorrhea is present; adhesions are the crucial test. What is the real pathology of these cases? Coe and others assert inflammation. Is the pathology parallel with certain disease in the liver and kidneys? If so the symptomatology is unlike. Removal to cure the dysmenorrhea may succeed for menstruation stops; the pathological cause is not demonstrated. The argument is much the same for so-called "cystic ovaries"-small cysts seldom larger than a buckshot embedded in the stroma or projecting from the surface of the ovary. Upon the altar of this startling phrase ovaries are still sacrificed-a practice which represents often superficial examination and pathological error. The ovary may be loose, but the cysts are said to be the end-product of inflammation, possibly