Part 8

(f) _Malignant Disease of the Uterus._--The varieties of malignant disease met with in the uterus are sarcoma, carcinoma and chorion-epithelioma malignum. Sarcomata may occur in the body and in the neck. They occur at an earlier age than carcinomata. Marked enlargement and haemorrhage are the symptoms. The differential diagnosis is microscopic. Extirpation of the uterus is the only chance of prolonging life. The age at which women are most subject to carcinoma (cancer) of the uterus is towards the decline of sexual life. Of 3385 collected cases of cancer of the uterus 1169 occurred between 40 and 50, and 856 between 50 and 60. In contradistinction to fibroid tumours it frequently arises after the menopause. It may be divided into cancer of the body and cancer of the neck (cervix). Cancer of the neck of the uterus is almost exclusively confined to women who have been pregnant (Bland-Sutton). Predisposing causes may be injuries during delivery. The symptoms which induce women to seek medical aid are haemorrhage, foetid discharge, and later pain and cachexia. An unfortunate belief amongst the public that the menopause is associated with irregular bleeding and offensive discharges has prevented many women from seeking medical advice until too late. It cannot be too widely understood that cancer of the cervix is in its early stages a purely local disease, and if removed in this stage usually results in cure. So important is the recognition of this fact in the saving of human life that at the meeting of the British Medical Association in April 1909 the council issued for publication a special appeal to medical practitioners, midwives and nurses, and directed it to be published in British and colonial medical and nursing journals. It will be useful to quote here a part of the appeal directed to midwives and nurses: "Cancer may occur at any age and in a woman who looks quite well, and who may have no pain, no wasting, no foul discharge and no profuse bleeding. To wait for pain, wasting, foul discharge or profuse bleeding is to throw away the chance of successful treatment. The early symptoms of cancer of the womb are:--(1) bleeding which occurs after the change of life, (2) bleeding after sexual intercourse or after a vaginal douche, (3) bleeding, slight or abundant, even in young women, if occurring between the usual monthly periods, and especially when accompanied by a bad-smelling or watery blood-tinged discharge, (4) thin watery discharge occurring at any age." On examination the cervix presents certain characteristic signs, though these may be modified according to the variety of cancer present. Hard nodules or definite loss of substance, extreme friability and bleeding after slight manipulation, are suspicious. Epithelial cancer of the cervix may assume a proliferating ulcerative type, forming the well-known "cauliflower" excrescence. The treatment of cancer of the cervix is free removal at the earliest possible moment. Cancer of the body of the uterus is rare before the 45th year. It is most frequent at or subsequent to the menopause. The majority of the patients are nulliparae (Bland-Sutton). The signs are fitful haemorrhages after the menopause, followed by profuse and offensive discharges. The uterus on examination often feels enlarged. The diagnosis being made, hysterectomy (removal of the uterus) is the only treatment. Cancer of the body of the uterus may complicate fibroids. Chorion-epithelioma malignum (deciduoma) was first described in 1889 by Sänger and Pfeiffer. It is a malignant disease presenting microscopic characters resembling decidual tissue. It occurs in connexion with recent pregnancy, and particularly with the variety of abortion termed hydatid mole. In many cases it destroys life with a rapidity unequalled by any other kind of growth. It quickly ulcerates and infiltrates the uterine tissues, forming metastatic growths in the lung and vagina. Clinically it is recognized by the occurrence after pregnancy of violent haemorrhages, progressive cachexia and fever with rigors. Recent suggestions have been made as to chorion-epithelioma being the result of pathological changes in the lutein tissue of the ovary. The growth is usually primary in the uterus, but may be so in the Fallopian tubes and in the vagina. A few cases have been recorded unconnected with pregnancy. The virulence of chorion-epithelioma varies, but in the present state of our knowledge immediate removal of the primary growth along with the affected organ is the only treatment.

_Diseases of the Fallopian Tubes._--The Fallopian tubes or oviducts are liable to inflammatory affections, tuberculosis, sarcomata, cancer, chorion-epithelioma and tubal pregnancy. Salpingitis (inflammation of the oviducts) is nearly always secondary to septic infection of the genital tract. The chief causes are septic endometritis following labour or abortion, gangrene of a myoma, gonorrhoea, tuberculosis and cancer of the uterus; it sometimes follows the specific fevers. When the pus escapes from the tubes into the coelom it sets up pelvic peritonitis. When the inflammation is adjacent to the ostium it leads to the matting together of the tubal fimbriae and glues them to an adjacent organ. This seals the ostium. The occluded tube may now have an accumulation of pus in it (pyosalpinx). When in consequence of the sealing of the ostium the tube becomes distended with serous fluid it is termed hydrosalpinx. Haematosalpinx is a term applied to the non-gravid tube distended with blood; later the tubes may become sclerosed. Acute septic salpingitis is ushered in by a rigor, the temperature rising to 103°, 104° F., with severe pain and constitutional disturbance. The symptoms may become merged in those of general peritonitis. In chronic disease there is a history of puerperal trouble followed by sterility, with excessive and painful menstruation. Acute salpingitis requires absolute rest, opium suppositories and hot fomentations. With urgent symptoms removal of the inflamed adnexa must be resorted to. Chronic salpingitis often renders a woman an invalid. Permanent relief can only be afforded by surgical intervention. Tuberculous salpingitis is usually secondary to other tuberculous infections. The Fallopian tubes may be the seat of malignant disease. This is rarely primary. By far the most important of the conditions of the Fallopian tubes is tubal pregnancy (or ectopic gestation). It is now known that fertilization of the human ovum by the spermatozoon may take place even when the ovum is in its follicle in the ovary, for oosperms have been found in the ovary and Fallopian tubes as well as in the uterus. Belief in ovarian pregnancy is of old standing, and had been regarded as possible but unproved, no case of an early embryo in its membranes in the sac of an ovary being forthcoming, until the remarkable case published by Dr Catherine van Tussenboek of Amsterdam in 1899 (Bland-Sutton). Tubal pregnancy is most frequent in the left tube; it sometimes complicates uterine pregnancy; rarely both tubes are pregnant. When the oosperm lodges in the ampulla or isthmus it is called tubal gestation; when it is retained in the portion traversing the uterine wall it is called tubo-uterine gestation. Wherever the fertilized ovum remains and implants its villi the tube becomes turgid and swollen, and the abdominal ostium gradually closes. The ovum in this situation is liable to apoplexy, forming tubal mole. When the abdominal ostium remains pervious the ovum may escape into the coelomic cavity (tubal abortion); death from shock and haemorrhage into the abdominal cavity may result. When neither of these occurrences has taken place the ovum continues to grow inside the tube, the rupture of the distended tube usually taking place between the sixth and the tenth week. The rupture of the tube may be intraperitoneal or extraperitoneal. The danger is death from haemorrhage occurring during the rupture, or adhesions may form, the retained blood forming a haematocele. The ovum may be destroyed or may continue to develop. In rare cases rupture may not occur, the tube bulging into the peritoneal cavity; and the foetus may break through the membranes and lie free among the intestines, where it may die, becoming encysted or calcified. The tubal placenta possesses foetal structures, the true decidua forming in the uterus. The signs suggestive of tubal pregnancy before rupture are missed periods, pelvic pains and the presence of an enlarged tube. When rupture takes place it is attended in both varieties with sudden and severe pain and more or less marked collapse, and a tumour may or may not be felt according to the situation of the rupture. There is a general "feeling of something having given way." If diagnosed before rupture, the sac must be removed by abdominal section. In intraperitoneal rupture immediate operation affords the only chance of saving life. In extraperitoneal rupture the foetus may occasionally remain alive until full term and be rescued by abdominal section, if the condition is recognized, or a false labour may take place, accompanied by death of the foetus.

_Diseases of the Ovaries and Parovarium._--The ovaries undergo striking changes at puberty, and again at the menopause, after which there is a gradual shrinkage. One or both may be absent or malformed, or they are subject to displacements, being either undescended, contained in a hernia or prolapsed. Either of these conditions, if a source of pain, may necessitate their removal. The ovary is also subject to haemorrhage or apoplexy. Acute inflammations (oöphorites) are constantly associated with salpingitis or other septic conditions of the genital tract or with an attack of mumps. The relation of oöphoritis to mumps is at present unknown. Acute oöphoritis may culminate in abscess but more usually adhesions are formed. The surgical treatment is that of pyosalpinx. Chronic inflammation may follow acute or be consequent on pelvic cellulitis. Its constant features are more or less pain followed by sterility. The ovary may be the seat of tuberculosis, which is generally secondary to other lesions. Suppuration and abscess of the ovary also occur. Perioöphoritis, or chronic inflammation in the neighbourhood, may also involve the gland. The cause of cirrhosis of the ovaries is unknown, though it may be associated with cirrhotic liver. The change is met with in women between 20 and 40 years of age, the ovaries being in a shrunken, hard, wrinkled condition. Under ovarian neuralgia are grouped indefinite painful symptoms occurring frequently in neurotic and alcoholic subjects, and often worse during menstruation. The treatment, whether local or operative, is usually unsatisfactory. The ovary is frequently the seat of tumours, dermoids and cysts. Cysts may be simple, unilocular or multilocular, and may attain an enormous size. The largest on record was removed by Dr Elizabeth Reifsnyder of Shanghai, and contained 100 litres of fluid, and the patient recovered. The operation is termed ovariotomy. Dermoid cysts containing skin, bones, teeth and hair, are of frequent growth in the ovary, and have attained the weight of from 20 to 40 kilogrammes. In one case a girl weighed 27 kilogrammes and her tumour 44 kilogrammes (Keen). Papillomatous cysts also occur in the ovary. Parovarian and Gärtnerian cysts are found, and adenomata form 20% of all ovarian cysts. Occasionally the tunic of peritoneum surrounding the ovary becomes distended with serous fluid. This is termed ovarian hydrocele. Ovarian fibroids occur, and malignant disease (sarcoma and carcinoma) is fairly frequent, sarcoma being the most usual ovarian tumour occurring before puberty. Carcinoma of the ovary is rarely primary, but it is a common situation for secondary cancer to that of the breast, gall-bladder or gastro-intestinal tract. The treatment of all rapidly-growing tumours of the ovary is removal.

_Diseases of the Pelvic Peritoneum and Connective Tissue._--Women are excessively liable to peritoneal infections. (1) Septic infection often follows acute salpingitis and may give rise to pelvic peritonitis (perimetritis), which may be adhesive, serous or purulent. It may follow the rupture of ovarian or dermoid cysts, rupture of the uterus, extra uterine pregnancy or extension from pyosalpinx. The symptoms are severe pain, fever, 103° F. and higher, marked constitutional disturbances, vomiting, restlessness, even delirium. The abdomen is fixed and tympanitic. Its results are the formation of adhesions causing abnormal positions of the organs, or chronic peritonitis may follow. The treatment is rest in bed, opium, hot stupes to the abdomen and quinine. (2) Epithelial infections take place in the peritoneum in connexion with other malignant growths. (3) Hydroperitoneum, a collection of free fluid in the abdominal cavity, may be due to tumours of the abdominal viscera or to tuberculosis of the peritoneum. (4) Pelvic cellulitis (parametritis) signifies the inflammation of the connective tissue between the folds of the broad ligament (mesometrium). The general causes are septic changes following abortion, delivery at term (especially instrumental delivery), following operations on the uterus or salpingitis. The symptoms are chill followed by severe intrapelvic pain and tension, fever 100° to 102° F. There may be nausea and vomiting, diarrhoea, rectal tenseness and dysuria. If consequent on parturition the lochia cease or become offensive. On examination there is tenderness and swelling in one flank and the uterus becomes fixed and immovable in the exudate as if embedded in plaster of Paris. The illness may go to resolution if treated by rest, opium, hot stupes or icebags and glycerine tampons, or may go on to suppuration forming pelvic abscess, which signifies a collection of pus between the layers of the broad ligament. The pus in a pelvic abscess may point and escape through the walls of the vagina, rectum or bladder. It occasionally points in the groin. If the pus can be localized an incision should be made and the abscess drained. The tumours which arise in the broad ligament are haematocele, solid tumours (as myomata, lipomata and sarcomata), and echinnococcus colonies (hydatids).

BIBLIOGRAPHY.--Albutt, Playfair and Eden, _System of Gynaecology_ (1906); McNaughton Jones, _Manual of Diseases of Women_ (1904); Bland-Sutton and Giles, _Diseases of Women_ (1906); C. Lockyer, "Lutein Cysts in association with Chorio-Epithelioma," _Journal of Obstetrics and Gynaecology_ (January, 1905); W. Stewart McKay, _History of Ancient Gynaecology_; Hart and Barbour, _Diseases of Women_; Howard Kelly, _Operative Gynaecology_. (H. L. H.)

GYÖNGYÖSI, ISTVÁN [STEPHEN] (1620-1704), Hungarian poet, was born of poor but noble parents in 1620. His abilities early attracted the notice of Count Ferencz Wesselényi, who in 1640 appointed him to a post of confidence in Fülek castle. Here he remained till 1653, when he married and became an assessor of the judicial board. In 1681 he was elected as a representative of his county at the diet held at Soprony (Oedenburg). From 1686 to 1693, and again from 1700 to his death in 1704, he was deputy lord-lieutenant of the county of Gömör. Of his literary works the most famous is the epic poem _Murányi Venus_ (Caschau, 1664), in honour of his benefactor's wife Maria Szécsi, the heroine of Murány. Among his later productions the best known are _Rózsa-Koszorú_, or Rose-Wreath (1690), _Kemény-János_ (1693), _Cupidó_ (1695), _Palinodia_ (1695) and _Chariklia_ (1700).

The earliest edition of his collected poetical works is by Dugonics (Pressburg and Pest, 1796); the best modern selection is that of Toldy, entitled _Gyöngyösi István válogatott poétai munkái_ (Select poetical works of Stephen Gyöngyösi, 2 vols., 1864-1865).

GYÖR (Ger. _Raab_), a town of Hungary, capital of a county of the same name, 88 m. W. of Budapest by rail. Pop. (1900) 27,758. It is situated at the confluence of the Raab with the Danube, and is composed of the inner town and three suburbs. Györ is a well-built town, and is the seat of a Roman Catholic bishop. Amongst its principal buildings are the cathedral, dating from the 12th century, and rebuilt in 1639-1654; the bishop's palace; the town hall; the Roman Catholic seminary for priests and several churches. There are manufactures of cloth, machinery and tobacco, and an active trade in grain and horses. Twenty miles by rail W. S. W. of the town is situated Csorna, a village with a Premonstratensian abbey, whose archives contain numerous valuable historical documents.

Györ is one of the oldest towns in Hungary and occupies the site of the Roman _Arabona_. It was already a place of some importance in the 10th century, and its bishopric was created in the 11th century. It was a strongly fortified town which resisted successfully the attacks of the Turks, into whose hands it fell by treachery in 1594, but they retained possession of it only for four years. Montecucculi made Györ a first-class fortress, and it remained so until 1783, when it was abandoned. At the beginning of the 19th century, the fortifications were re-erected, but were easily taken by the French in 1809, and were again stormed by the Austrians on the 28th of June 1849.

About 11 m. S.E. of Györ on a spur of the Bakony Forest lies the famous Benedictine abbey of Pannonhalma (Ger. _St Martinsberg_; Lat. _Mons Sancti Martini_), one of the oldest and wealthiest abbeys of Hungary. It was founded by King St Stephen, and the original deed from 1001 is preserved in the archives of the abbey. The present building is a block of palaces, containing a beautiful church, some of its parts dating from the 12th century, and lies on a hill 1200 ft. high. The church has a tower 130 ft. high. In the convent there are a seminary for priests, a normal school, a gymnasium and a library of 120,000 vols. The chief abbot has the rank of a bishop, and is a member of the Upper House of the Hungarian parliament, while in spiritual matters he is subordinate immediately to the Roman curia.

GYP, the pen name of SIBYLLE GABRIELLE MARIE ANTOINETTE RIQUETI DE MIRABEAU, Comtesse de Martel de Janville (1850- ) French writer, who was born at the château of Koetsal in the Morbihan. Her father, who was the grandson of the vicomte de Mirabeau and great-nephew of the orator, served in the Papal Zouaves, and died during the campaign of 1860. Her mother, the comtesse de Mirabeau, in addition to some graver compositions, contributed to the _Figaro_ and the _Vie parisienne_, under various pseudonyms, papers in the manner successfully developed by her daughter. Under the pseudonym of "Gyp" Madame de Martel, who was married in 1869, sent to the _Vie parisienne_, and later to the _Revue des deux mondes_, a large number of social sketches and dialogues, afterwards reprinted in volumes. Her later work includes stories of a more formal sort, essentially differing but little from the shorter studies. The following list includes some of the best known of Madame de Martel's publications, nearly seventy in number: _Petit Bob_ (1882); _Autour du mariage_ (1883); _Ce que femme veut_ (1883); _Le Monde à côté_ (1884), _Sans voiles_ (1885); _Autour du divorce_ (1886); _Dans le train_ (1886); _Mademoiselle Loulou_ (1888); _Bob au salon_ (1888-1889); _L'Education d'un prince_ (1890); _Passionette_ (1891); _Ohé! la grande vie_ (1891); _Une Élection à Tigre-sur-mer_ (1890), an account of "Gyp's" experiences in support of a Boulangist candidate; _Mariage civil_ (1892); _Ces bons docteurs_ (1892); _Du haut en bas_ (1893); _Mariage de chiffon_ (1894); _Leurs âmes_ (1895); _Le Coeur d'Ariane_ (1895); _Le Bonheur de Ginette_ (1896); _Totote_ (1897); _Lune de miel_ (1898); _Israël_ (1898); _L'Entrevue_ (1899); _Le Pays des champs_ (1900); _Trop de chic_ (1900); _Le Friquet_ (1901); _La Fée_ (1902); _Un Mariage chic_ (1903); _Un Ménage dernier cri_ (1903); _Maman_ (1904); _Le Coeur de Pierrette_ (1905). From the first "Gyp," writing of a society to which she belonged, displayed all the qualities which have given her a distinct, if not pre-eminent, position among writers of her class. Those qualities included an intense faculty of observation, much skill in innuendo, a mordant wit combined with some breadth of humour, and a singular power of animating ordinary dialogues without destroying the appearance of reality. Her Parisian types of the spoiled child, of the precocious schoolgirl, of the young bride, and of various masculine figures in the gay world, have become almost classical, and may probably survive as faithful pictures of luxurious manners in the 19th century. Some later productions, inspired by a violent anti-Semitic and Nationalist bias, deserve little consideration. An earlier attempt to dramatize _Autour du mariage_ was a failure, not owing to the audacities which it shares with most of its author's works, but from lack of cohesion and incident. More successful was _Mademoiselle Ève_ (1895), but indeed "Gyp's" successes are all achieved without a trace of dramatic faculty. In 1901 Madame de Martel furnished a sensational incident in the Nationalist campaign during the municipal elections in Paris. She was said to have been the victim of a kidnapping outrage or piece of horseplay provoked by her political attitude, but though a most circumstantial account of the outrages committed on her and of her adventurous escape was published, the affair was never clearly explained or verified.

GYPSUM, a common mineral consisting of hydrous calcium sulphate, named from the Gr. [Greek: gypsos], a word used by Theophrastus to denote not only the raw mineral but also the product of its calcination, which was employed in ancient times, as it still is, as a plaster. When crystallized, gypsum is often called selenite, the [Greek: selênitês] of Dioscorides, so named from [Greek: selênê], "the moon," probably in allusion to the soft moon-like reflection of light from some of its faces, or, according to a legend, because it is found at night when the moon is on the increase. The granular, marble-like gypsum is termed alabaster (q.v.).

Gypsum crystallizes in the monoclinic system, the habit of the crystals being usually either prismatic or tabular; in the latter case the broad planes are parallel to the faces of the clinopinacoid. The crystals may become lenticular by curvature of certain faces. In the characteristic type represented in fig. 1, f represents the prism, l the hemi-pyramid and P the clinopinacoid. Twins are common, as in fig. 2, forming in some cases arrow-headed and swallow-tailed crystals. Cleavage is perfect parallel to the clinopinacoid, yielding thin plates, often diamond-shaped, with pearly lustre; these flakes are usually flexible, but may be brittle, as in the gypsum of Montmartre. Two other cleavages are recognized, but they are imperfect. Crystals of gypsum, when occurring in clay, may enclose much muddy matter; in other cases a large proportion of sand may be mechanically entangled in the crystals without serious disturbance of form; whilst certain crystals occasionally enclose cavities with liquid and an air-bubble. Gypsum not infrequently becomes fibrous. This variety occurs in veins, often running through gypseous marls, with the fibres disposed at right angles to the direction of the vein. Such gypsum when cut and polished has a pearly opalescence, or satiny sheen, whence it is called satin-spar (q.v.).

[Illustration: FIG. 1.]

[Illustration: FIG. 2.]

Gypsum is so soft as to be scratched even by the finger-nail (H = 1.5 to 2). Its specific gravity is about 2.3. The mineral is slightly soluble in water, one part of gypsum being soluble, according to G. K. Cameron, in 372 parts of pure water at 26° C. Waters percolating through gypseous strata, like the Keuper marls, dissolve the calcium sulphate and thus become permanently hard or "selenitic." Such water has special value for brewing pale ale, and the water used by the Burton breweries is of this character; hence the artificial dissolving of gypsum in water for brewing purposes is known as "burtonization." Deposits of gypsum are formed in boilers using selenitic water.