Gynaecology

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.

(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.