patient feels exhausted for several days, and then recovers until the time for the next menstruation appears. After having passed through a number of attacks the subjects look very miserable, are emaciated, irritable and unable during the intervals to attend to their usual duties. The appetite and digestion generally suffer, so that there is even a certain degree of chlorosis apparent.

We recognize simple non-mechanical dysmenorrhoea, first, by the absence of displacement or enlargement of the uterus, and of increased secretion or disease of the mucous membrane, while the entire uterine wall and especially the mucous membrane is extremely sensitive upon introduction of the sound. But if we can discover nothing abnormal in the uterus during menstruation, the ovaries and tubes must be carefully examined for anomalies of any kind.

Not infrequently parovarian varicocele or a movable kidney may be the seat of the pain. To guard against error the condition of the uterus and bladder must be carefully examined; also the presence of uric acid deposits, etc., must be sought, since calculous nephritis may cause attacks which are very similar to those of dysmenorrhoea, the only difference being that the pain is situated in the neighborhood of the kidney and seldom or never in the pelvis. It thus becomes evident that dysmenorrhoea is a symptom of a great variety of affections; also, that in the beginning of an attack none of these affections can be diagnosticated with certainty; and that, even after a diagnosis has once been made, the disease in question may possibly be simply an effect of the dysmenorrhoea. We are therefore forced to include a long list of complaints under the common term dysmenorrhoea, and treat them symptomatically.

The first indication consists in removing from the patient every cause which is known by experience to aggravate her suffering, e. g., cold, direct irritation and hyperemia of the uterus, etc.

When possible she should remain in bed at the beginning of the flow, and at the same time avoid all mental effort and worry, for such patients are inclined to be nervous and excitable. Since cold increases their distress, most of these patients cover themselves with heavy bed-clothing, apply hot com

presses, and drink hot teas in order to produce free perspiration, and this affords much relief. We will add that thoroughly warming the cold hands and feet is to be recommended. Irritation of the uterus, and great pressure upon it, as from constipation, are to be avoided, and frequent examinations are unnecessary and harmful. Increased blood pressure, as from an overloaded stomach or distended intestines, must be prevented. Any existing bronchial catarrh must be treated, and the patient kept upon her back. We have many direct ways of relieving congestion of the pelvic organs and thus lessening the pain, as by sinapisms applied for ten or fifteen minutes to the most painful spots, or by bathing the hands in water as hot as can be borne.

When all other means prove without avail, we can resort to the use of narcotics, of which there is a great variety. It is only too frequently the case that young physicians are prone to the administration of morphia in hypodermatic injections whenever their patients complain of violent pain. In the dysmenorrhoea of young girls, this treatment is very agreeable to the parents, because they naturally are averse to examinations and at the same time do not wish to see their children suffer. It is in just such cases that the drug is abused, and that many a patient acquires the morphine habit. A knowledge of the method of employing the syringe must never be imparted to such patients nor to their nurses. When a resort to the use of narcotics is unavoidable, one should begin with injections of hyoscyamus, and subsequently give extract of belladonna in suppositories, and finally, tincture of opium by the rectum. Later, fifteen-grain doses of chloral hydrate may be given by the rectum; inunction of the abdominal walls with narcotic ointments ordered; Dover's powder given internally as occasion demands; and, finally, but always as a last resort, morphine injected hypodermatically.

When there is much discomfort for days preceding the flow, and there is passive hyperemia of the uterus, depletion by scarification of the cervical mucous membrane is often beneficial.

In conclusion, the treatment should be directed to all recognizable causes, e.g., stenosis, catarrh, displacements, etc.

4. Membranous Dysmenorrhoea. Endometritis Exfoliativa.
Endometritis Dissecans. Decidua Menstrualis.

We have already stated that in healthy menstruation the mucous membrane remains almost intact, fatty degeneration and exfoliation being always exceptional. When, therefore, larger or

smaller pieces or tube-shaped portions or, indeed, complete casts of the uterine mucous membrane are discharged at each period,

and the process is attended with more or less pain, we designate the condition as membranous dysmenorrhea.

As pointed out by Haussmann, Morgagni was the first to recognize this disease, in 1723. His patient was a woman, aged 34 years, who had been repeatedly confined, had aborted and had suffered from leucorrhoea.

These membranes show a smooth reddish inner surface, upon which the orifices of the utricular glands may be seen by the naked eye, and an external rough uneven surface, which appears as though torn from its connections, and it occasionally contains small blood clots. It is of unequal thickness, is usually very thin and almost transparent at the points where the walls join each other, and somewhat thicker at those portions where the mucous membrane has not been uniformly exfoliated. In addition to this peculiarity, the membrane shows the changes characteristic of endometritis, therefore, the term endometritis dissecans is not inappropriate. In many cases the discharged membrane is a complete sac containing three openings corresponding to the os uteri and the orifices of the tubes. Microscopically we see the utricular glands and the small celled proliferation of the interglandular tissue, which is easily differentiated from the large irregular decidua cells of pregnancy. That we have not to deal with the product of an abortion is shown by the absence of the villi. Sometimes this exfoliative endometritis is associated with an exfoliative colpitis; large pieces of membrane, consisting of nucleated pavement epithelium, are discharged, and these are followed by tenacious fibrinous portions like those thrown off after the application of a concentrated solution of alum; yet, I have seen such a colpitis dissecans occur in a virgin who had not used injections. According to Cohnstein, exfoliative colpitis was first described by Farre, in 1858. These membranes are discharged at irregular intervals, wholly independent of menstruation, though more frequently during the flow.

Symptoms.-The menses begin with a feeling of heat and burning, discomfort, chilliness and occasionally with fever. The graver and more obstinate cases are attended by hysterical convulsions, and are usually preceded by circumscribed pain above the symphysis or around the umbilicus. The flow is by no means

always profuse, indeed, it may be scanty. The time of the discharge of the membrane varies from the second to the fifth day.

Occasionally, the exfoliation occurs almost with regularity, and is painless. In many patients the pains are developed gradually, in others, they are intense from the start, the severest paroxysms preceding the discharge of the membrane.

The patient soon becomes very weak and miserable. For days after the discharge there is a feeling of soreness, and there is increased secretion mixed with blood. In one instance I cured my patient by employing scarification; she conceived, was confined and remained well during the puerperium; when her menses returned, however, the membranous dysmenorrhoea again appeared. I was not able to treat her after leaving Mecklenburg, and could not follow up the subsequent history. My patient who had dysmenorrhoea combined with exfoliative vaginitis, suffered from the most distressing symptoms; there were pains in the region of the ovaries, hyperesthesia of the skin, feeling of syncope without loss of consciousness, slowed cardiac action and scanty micturition; she also complained of heat and burning in the abdomen, extreme exhaustion, great sensitiveness to sounds, anorexia, constipation and occasional vomiting during the attack, but never had any fever.

Etiology.-My personal experience by no means confirms the assertion made by some writers, that membranous dysmenorrhoea and exfoliative colpitis are usually caused by constitutional diseases, such as anemia, chlorosis, scrofula or tuberculosis. I have no reason to believe that it is hereditary, neither have I ever found the existence of syphilis in any case. One patient had a dermoid ovarian cyst, but none of the others had any genital affection. Another attributed her condition to over-exertion and concussion from coasting in St. Petersburg. The aetiology is still very doubtful. It is obvious that it might be caused by protracted catarrh. Many of my patients were parous women.

Treatment.-Dilatation of the uterine cavity, discission of the cervical canal, cauterization of the uterine mucous membrane with nitrate of silver, tannin, tincture of iodine and carbolic acid, curetting the uterus, scarifying its mucous membrane and the application of leeches to the vaginal portion have all been recommended, and used by the author. I have also had under my care