Part 7

Gynaecology may be said to be one of the most ancient branches of medicine. The papyrus of Ebers, which is one of the oldest known works on medicine and dates from 1550 B.C., contains references to diseases of women, and it is recorded that specialism in this branch was known amongst Egyptian medical practitioners. The Vedas contain a list of therapeutic agents used in the treatment of gynaecological diseases. The treatises on gynaecology formerly attributed to Hippocrates (460 B.C.) are now said to be spurious, but the wording of the famous oath shows that he was at least familiar with the use of gynaecological instruments. Diocles Carystius, of the Alexandrian school (4th century B.C.), practised this branch, and Praxagoras of Cos, who lived shortly after, opened the abdomen by laparotomy. While the Alexandrine school represented Greek medicine, Greeks began to practise in Rome, and in the first years of the Christian era gynaecologists were much in demand (Häser). A speculum for gynaecological purposes has been found in the ruins of Pompeii, and votive offerings of anatomical parts found in the temples show that various gynaecological malformations were known to the ancients. Writers who have treated of this branch are Celsus (50 B.C.-A.D. 7) and Soranus of Ephesus (A.D. 98-138), who refers in his works to the fact that the Roman midwives frequently called to their aid practitioners who made a special study of diseases of women. These midwives attended the simpler gynaecological ailments. This was no innovation, as in Athens, as mentioned by Hyginus, we find one Agnodice, a midwife, disguising herself in man's attire so that she might attend lectures on medicine and diseases of women. After instruction she practised as a gynaecologist. This being contrary to Athenian law she was prosecuted, but was saved by the wives of some of the chief men testifying on her behalf. Besides Agnodice we have Sotira, who wrote a work on menstruation which is preserved in the library at Florence, while Aspasia is mentioned by Aetius as the author of several chapters of his work. It is evident that during the Roman period much of the gynaecological work was in the hands of women. Martial alludes to the "_feminae medicae_" in his epigram on Leda. These women must not be confounded with the midwives who on monuments are always described as "obstetrices." Galen devotes the sixth chapter of his work _De locis affectis_ to gynaecological ailments. During the Byzantine period may be mentioned the work of Oribasius (A.D. 325) and Moschion (2nd century A.D.) who wrote a book in Latin for the use of matrons and midwives ignorant of Greek.

In modern times James Parsons (1705-1770) published his _Elenchus gynaicopathologicus et obstetricarius_, and in 1755 Charles Perry published his _Mechanical account and explication of the hysterical passion and of all other nervous disorders incident to the sex, with an appendix on cancers_. In the early part of the 19th century fresh interest in diseases of women awakened. Joseph Récamier (1774-1852) by his writings and teachings advocated the use of the speculum and sound. This was followed in 1840 by the writings of Simpson in England and Huguier in France. In 1845 John Hughes Bennett published his great work on inflammation of the uterus, and in 1850 Tilt published his book on ovarian inflammation. The credit of being the first to perform the operation of ovariotomy is now credited to McDowell of Kentucky in 1809, and to Robert Lawson Tait (1845-1899) in 1883 the first operation for ruptured ectopic gestation.

_Menstruation._--Normal menstruation comprises the escape of from 4 to 6 oz. of blood together with mucus from the uterus at intervals of twenty-eight days (more or less). The flow begins at the age of puberty, the average age of which in England is between fourteen and sixteen years. It ceases between forty-five and fifty years of age, and this is called the menopause or climacteric period, commonly spoken of as "the change of life." Both the age of puberty and that of the menopause may supervene earlier or later according to local conditions. At both times the menstrual flow may be replaced by haemorrhage from distant organs (epistaxis, haematemesis, haemoptysis); this is called _vicarious menstruation_. Menstruation is usually but not necessarily coincident with ovulation. The usual disorders of menstruation are: (1) _amenorrhoea_ (absence of flow), (2) _dysmenorrhoea_ (painful flow), (3) _menorrhagia_ (excessive flow), (4) _metrorrhagia_ (excessive and irregular flow). Amenorrhoea may arise from physiological causes, such as pregnancy, lactation, the menopause; constitutional causes, such as phthisis, anaemia and chlorosis, febrile disorders, some chronic intoxications, such as morphinomania, and some forms of cerebral disease; local causes, which include malformations or absence of one or more of the genital parts, such as absence of ovaries, uterus or vagina, atresia of vagina, imperforate cervix, disease of the ovaries, or sometimes imperforate hymen. The treatment of amenorrhoea must be directed towards the cause. In anaemia and phthisis menstruation often returns after improvement in the general condition, with good food and good sanitary conditions, an outdoor life and the administration of iron or other tonics. In local conditions of imperforate hymen, imperforate cervix or ovarian disease, surgical interference is necessary. Amenorrhoea is permanent when due to absence of the genital parts. The causes of dysmenorrhoea are classified as follows: (1) ovarian, due to disease of the ovaries or Fallopian tubes; (2) obstructive, due to some obstacle to the flow, as stenosis, flexions and malpositions of the uterus, or malformations; (3) congestive, due to subinvolution, chronic inflammation of the uterus or its lining membrane, fibroid growths and polypi of the uterus, cardiac or hepatic disease; (4) neuralgic; (5) membranous. The foremost place in the treatment of dysmenorrhoea must be given to aperients and purgatives administered a day or two before the period is expected. By this means congestion is reduced. Hot baths are useful, and various drugs such as hyoscyanus, cannabis indica, phenalgin, ammonol or phenacetin have been prescribed. Medicinal treatment is, however, only palliative, and flexions and malpositions of the uterus must be corrected, stenosis treated by dilatation, fibroid growths if present removed, and endometritis when present treated by local applications or curetting according to its severity. Menorrhagia signifies excessive bleeding at the menstrual periods. Constitutional causes are purpura, haemophilia, excessive food and alcoholic drinks and warm climates; while local causes are congestion and displacements of the uterus, endometritis, subinvolution, retention of the products of conception, new growths in the uterus such as mucous and fibroid polypi, malignant growths, tubo-ovarian inflammation and some ovarian tumours. Metrorrhagia is a discharge of blood from the uterus, independent of menstruation. It always arises from disease of the uterus or its appendages. Local causes are polypi, retention of the products of conception, extra uterine gestation, haemorrhages in connexion with pregnancy, and new growths in the uterus. In the treatment of both menorrhagia and metrorrhagia the local condition must be carefully ascertained. When pregnancy has been excluded, and constitutional causes treated, efforts should be made to relieve congestion. Uterine haemostatics, as ergot, ergotin, tincture of hydrastis or hamamelis, are of use, together with rest in bed. Fibroid polypi and other new growths must be removed. Irregular bleeding in women over forty years of age is frequently a sign of early malignant disease, and should on no account be neglected.

_Diseases of the External Genital Organs._--The vulva comprises several organs and structures grouped together for convenience of description (see REPRODUCTIVE SYSTEM). The affections to which these structures are liable may be classified as follows: (1) Injuries to the vulva, either accidental or occurring during parturition; these are generally rupture of the perinaeum. (2) _Vulvitis._ Simple Vulvitis is due to want of cleanliness, or irritating discharges, and in children may result from threadworms. The symptoms are heat, itching and throbbing, and the parts are red and swollen. The treatment consists of rest, thorough cleanliness and fomentations. Infective vulvitis is nearly always due to gonorrhoea. The symptoms are the same as in simple vulvitis, with the addition of mucopurulent yellow discharge and scalding pain on micturition; if neglected, extension of the disease may result. The treatment consists of rest in bed, warm medicated baths several times a day or fomentations of boracic acid. The parts must be kept thoroughly clean and discharges swabbed away. Diphtheritic vulvitis occasionally occurs, and erysipelas of the vulva may follow wounds, but since the use of antiseptics is rarely seen. (3) Vascular disturbances may occur in the vulva, including varix, haematoma, oedema and gangrene; the treatment is the same as for the same disease in other parts. (4) The vulva is likely to be affected by a number of cutaneous affections, the most important being erythema, eczema, herpes, lichen, tubercle, elephantiasis, vulvitis pruriginosa, syphilis and kraurosis. These affections present the same characters as in other parts of the body. _Kraurosis vulvae_, first described by Lawson Tait in 1875, is an atrophic change accompanied by pain and a yellowish discharge; the cause is unknown. Pruritis vulvae is due to parasites, or to irritating discharges, as leucorrhoea, and is frequent in diabetic subjects. The hymen may be occasionally imperforate and require incision. Cysts and painful carunculae may occur on the clitoris. Any part of the vulva may be the seat of new growths, simple or malignant.

_Diseases of the Vagina._--(1) Malformations. The vagina may be absent in whole or in part or may present a septum. Stenosis of the vagina may be a barrier to menstruation. (2) Displacements of the vagina; (a) cystocele, which is a hernia of the bladder into the vagina; (b) rectocele, a hernia of the rectum into the vagina. The cause of these conditions is relaxation of the tissues due to parturition. The palliative treatment consists in keeping up the parts by the insertion of a pessary; when this fails operative interference is called for. (3) Fistulae may form between the vagina and bladder or vagina and rectum; they are generally caused by injuries during parturition or the late stages of carcinoma. Persistent fistulae require operative treatment. The vagina normally secretes a thin opalescent acid fluid derived from the lymph serum and the shedding of squamous epithelium. This fluid normally contains the vagina bacillus. In pathological conditions of the vagina this secretion undergoes changes. For practical purposes three varieties of _vaginitis_ may be described: (a) simple catarrhal vaginitis is due to the same causes as simple vulvitis, and occasionally in children is important from a medico-legal aspect when it is complicated by vulvitis. The symptoms are heat and discomfort with copious mucopurulent discharge. The only treatment required is rest, with vaginal douches of warm unirritating lotions such as boracic acid or subacetate of lead. (b) Gonorrhoeal vaginitis is most common in adults. The patient complains of pain and burning, pain on passing water and discharge which is generally green or yellow. The results of untreated gonorrhoeal vaginitis are serious and far-reaching. The disease may spread up the genital passages, causing endometritis, salpingitis and septic peritonitis, or may extend into the bladder, causing cystitis. Strict rest should be enjoined, douches of carbolic acid (1 in 40) or of perchloride of mercury (1 in 2000) should be ordered morning and evening, the vagina being packed with tampons of iodoform gauze. Saline purgatives and alkaline diuretics should be given, (c) Chronic vaginitis (leucorrhoea or "the whites") may follow acute conditions and persist indefinitely. The vagina is rarely the seat of tumours, but cysts are common.

_Diseases of the Uterus._--The uterus undergoes important changes during life, chiefly at puberty and at the menopause. At puberty it assumes the pear shape characteristic of the mature uterus. At the menopause it shares in the general atrophy of the reproductive organs. It is subject to various disorders and misplacements. (a) _Displacements of the Uterus._--The normal position of the uterus, when the bladder is empty, is that of anteversion. We have therefore to consider the following conditions as pathological: anteflexion, retroflexion, retroversion, inversion, prolapse and procidentia. Slight anteflexion or bending forwards is normal; when exaggerated it gives rise to dysmenorrhoea, sterility and reflex nervous phenomena. This condition is usually congenital and is often associated with under-development of the uterus, from which the sterility results. The treatment is by dilatation of the canal or by a plastic operation. Retroflexion is a bending over of the uterus backwards, and occurs as a complication of retroversion (or displacement backwards). The causes are (1) any cause tending to make the fundus or upper part of the uterus extra heavy, such as tumours or congestion, (2) loss of tone of the uterine walls, (3) adhesions formed after cellulitis, (4) violent muscular efforts, (5) weakening of the uterine supports from parturition. The symptoms are dysmenorrhoea, pain on defaecation and constipation from the pressure of the fundus on the rectum; the patient is often sterile. The treatment is the replacing of the uterus in position, where it can be kept by the insertion of a pessary; failing this, operative treatment may be required. Retroversion when pathological is rarer than retroflexion. It may be the result of injury or is associated with pregnancy or a fibroid. The symptoms are those of retroflexion with feeling of pain and weight in the pelvis and desire to micturate followed by retention of urine due to the pressure of the cervix against the base of the bladder. The uterus must be skilfully replaced in position; when pessaries fail to keep it there the operation of hysteropexy gives excellent results.

Inversion occurs when the uterus is turned inside out. It is only possible when the cavity is dilated, either after pregnancy or by a polypus. The greater number of cases follow delivery and are acute. Chronic inversions are generally due to the weight of a polypus. The symptoms are menorrhagia, metrorrhagia and bladder troubles; on examination a tumour-like mass occupies the vagina. Reduction of the condition is often difficult, particularly when the condition has lasted for a long time. The tumour which has caused the inversion must be excised. Prolapse and procidentia are different degrees of the same variety of displacement. When the uterus lies in the vagina it is spoken of as prolapse, when it protrudes through the vulva it is procidentia. The causes are directly due to increased intra-abdominal pressure, increased weight of the uterus by fibroids, violent straining, chronic cough and weakening of the supporting structures of the pelvic floor, such as laceration of the vagina and perinaeum. Traction on the uterus from below (as a cervical tumour) may be a cause; advanced age, laborious occupations and frequent pregnancies are indirect causes. The symptoms are a "bearing down" feeling, pain and fatigue in walking, trouble with micturition and defaecation. The condition is generally obvious on examination. As a rule the uterus is easy to replace in position. A rubber ring pessary will often serve to keep it there. If the perinaeum is very much torn it may be necessary to repair it. Various operations for retaining the uterus in position are described. (b) _Enlargements of the Uterus_ (hypertrophy or hyperplasia). This condition may sometimes involve the uterus as a whole or may be most marked in the body or in the cervix. It follows chronic congestion or inflammatory prolapse, or any condition interfering with the circulation. The symptoms comprise local discomfort and sometimes dysmenorrhoea, leucorrhoea or menorrhagia. When the elongation occurs in the cervical portion the only possible treatment is amputation of the cervix. Atrophy of the uterus is normal after the menopause. It may follow the removal of the tubes and ovaries. Some constitutional diseases produce the same result, as tuberculosis, chlorosis, chronic morphinism and certain diseases of the central nervous system.

(c) _Injuries and Diseases resultant from Pregnancy._--The most frequent of these injuries is laceration of the cervix uteri, which is frequent in precipitate labour. Once the cervix is torn the raw surfaces become covered by granulations and later by cicatricial tissue, but as a rule they do not unite. The torn lips may become unhealthy, and the congestion and oedema spread to the body of the uterus. A lacerated cervix does not usually give rise to symptoms; these depend on the accompanying endometritis, and include leucorrhoea, aching and a feeling of weight. Lacerations are to be felt digitally. As lacerations predispose to abortion the operation of trachelorraphy or repair of the cervix is indicated. Perforation of the uterus may occur from the use of the sound in diseased conditions of the uterine walls. Superinvolution means premature atrophy following parturition. Subinvolution is a condition in which the uterus fails to return to its normal size and remains enlarged. Retention of the products of conception may cause irregular haemorrhages and may lead to a diagnosis of tumour. The uterus should be carefully explored.

(d) _Inflammations Acute and Chronic._--The mucous membrane lining the cervical canal and body of the uterus is called the endometrium. Acute inflammation or endometritis may attack it. The chief causes are sepsis following labour or abortion, extension of a gonorrhoeal vaginitis, or gangrene or infection of a uterine myoma. The puerperal endometritis following labour is an avoidable disease due to lack of scrupulous aseptic precautions.

Gonorrhoeal endometritis is an acute form associated with copious purulent discharge and well-marked constitutional disturbance. The temperature ranges from 99° to 105° F., associated with pelvic pain, and rigors are not uncommon. The tendency is to recovery with more or less protracted convalescence. The most serious complications are extension of the disease and later sterility. Rest in bed and intrauterine irrigation, followed by the introduction of iodoform pencils into the uterine cavity, should be resorted to, while pain is relieved by hot fomentations and sitz baths. Chronic endometritis may be the sequela of the acute form, or may be septic in origin, or the result of chronic congestion, acute retroflection or subinvolution following delivery or abortion. The varieties are glandular, interstitial, haemorrhagic and senile. The symptoms are disturbance of the menstrual function, headache, pain and pelvic discomfort, and more or less profuse thick leucorrhoeal discharge. The treatment consists in attention to the general health, with suitable laxatives and local injections, and in obstinate cases curettage is the most effectual measure. The disease is frequently associated with adenomatous disease of the cervix, formerly called erosion. In this disease there is a new formation of glandular elements, which enlarge and multiply, forming a soft velvety areola dotted with pink spots. This was formerly erroneously termed ulceration. The cause is unknown. It occurs in virgins as well as in mothers, but it often accompanies lacerations of the cervix. The symptoms are indefinite pain and leucorrhoea. The condition is visible on inspection with a speculum. The treatment is swabbing with iodized phenol or curettage. The body of the uterus may also be the seat of adenomatous disease. Tuberculosis may attack the uterus; this usually forms part of a general tuberculosis.

(e) _New Growths in the Uterus._--The uterus is the most common seat of new growths. From the researches of von Gurlt, compiled from the Vienna Hospital _Reports_, embracing 15,880 cases of tumour, females exceed males in the proportion of seven to three, and of this large majority uterine growths account for 25%. When we consider its periodic monthly engorgements and the alternate hypertrophy and involution it undergoes in connexion with pregnancy, we can anticipate the special proneness of the uterus to new growths. Tumours of the uterus are divided into benign and malignant. The benign tumours known as fibroids or myomata are very common. They are stated by Bayle to occur in 20% of women over 35 years of age, but happily in a great number of cases they are small and give rise to no symptoms. They are definitely associated with the period of sexual activity and occur more frequently in married women than in single, in the proportion of two to one (Winckel). It is doubtful if they ever originate after the menopause. Indeed if uncomplicated by changes in them they share in the general atrophy of the sexual organs which then takes place. They are divided according to their position in the tissues into intramural, subserous and submucous (the last when it has a pedicle forms a polypus), or as to the part of the uterus in which they develop into fibroids of the cervix and fibroids of the body. Intramural and submucous fibroids give rise to haemorrhage. The menses may be so increased that the patient is scarcely ever free from haemorrhage. The pressure of the growth may cause dysmenorrhoea, or pressure on the bladder and rectum may cause dysuria, retention or rectal tenesmus. The uterus may be displaced by the weight of the tumour. Secondary changes take place in fibroids, such as mucous degeneration, fatty metamorphosis, calcification, septic infection (sloughing fibroid) and malignant (sarcomatous) degeneration.

The modes in which fibroids imperil life are haemorrhage (the commonest of all), septic infection, which is one of the most dangerous, impaction when it fits the true pelvis so tightly that the tumour cannot rise, twisting of the pedicle by rotation, leading to sloughing and intestinal and urinary obstruction. When fibroids are complicated by pregnancy, impaction and consequent abortion may take place, or a cervical myoma may offer a mechanical obstacle to delivery or lead to serious post partem haemorrhage. In the treatment of fibroids various drugs (ergot, hamamelis, hydrastis canadensis) may be tried to control the haemorrhage, and repose and the injection of hot water (120° F.) are sometimes successful, together with electrical treatment. Surgical measures are needed, however, in severe recurrent haemorrhage, intestinal obstruction, sloughing and the co-existence of pregnancy. An endeavour must be made if possible to enucleate the fibroid, or hysterectomy (removal of the uterus) may be required. The operation of removal of the ovaries to precipitate the menopause has fallen into disuse.