(A. C. Se.)
GYMNOSTOMACEAE,an order of Ciliate Infusoria (q.v.), characterized by a closed mouth, which only opens to swallow food actively, and body cilia forming a general or partial investment (rarely represented by a girdle of membranellae), but not differentiated in different regions. With the Aspirotrochaceae (q.v.) it formed the Holotricha of Stein.
GYMPIE,a mining town of March county, Queensland, Australia, 107 m. N. of Brisbane, and 61 m. S. of Maryborough by rail. Pop. (1901) 11,959. Numerous gold mines are worked in the district, which also abounds in copper, silver, antimony, cinnabar, bismuth and nickel. Extensive undeveloped coal-beds lie 40 m. N. at Miva. Gympie became a municipality in 1880.
GYNAECEUM(Gr.γυναικεῖον, fromγυνή, woman), that part in a Greek house which was specially reserved for the women, in contradistinction to the “andron,” the men’s quarters; in the larger houses there was an open court with peristyles round, and as a rule all the rooms were on the same level; in smaller houses the servants were placed in an upper storey, and this seems to have been the case to a certain extent in the Homeric house of the Odyssey. “Gynaeconitis” is the term given by Procopius to the space reserved for women in the Eastern Church, and this separation of the sexes was maintained in the early Christian churches where there were separate entrances and accommodation for the men and women, the latter being placed in the triforium gallery, or, in its absence, either on one side of the church, the men being on the other, or occasionally in the aisles, the nave being occupied by the men.
GYNAECOLOGY(from Gr.γυνή, γυναικός, a woman, andλόγος, discourse), the name given to that branch of medicine which concerns the pathology and treatment of affections peculiar to the female sex.
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 1550B.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 (460B.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 centuryB.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 (50B.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 workDe locis affectisto gynaecological ailments. During the Byzantine period may be mentioned the work of Oribasius (A.D.325) and Moschion (2nd centuryA.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 hisElenchus gynaicopathologicus et obstetricarius, and in 1755 Charles Perry published hisMechanical 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 calledvicarious menstruation. Menstruation is usually but not necessarily coincident with ovulation. The usualdisorders 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 (seeReproductive 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 ofvaginitismay 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 inflammatoryprolapse, 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 HospitalReports, 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 oviductsare 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.
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 calledvicarious menstruation. Menstruation is usually but not necessarily coincident with ovulation. The usualdisorders 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 (seeReproductive 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 ofvaginitismay 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 inflammatoryprolapse, 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 HospitalReports, 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 oviductsare 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 poemMurányi Venus(Caschau, 1664), in honour of his benefactor’s wife Maria Szécsi, the heroine of Murány. Among his later productions the best known areRózsa-Koszorú, or Rose-Wreath (1690),Kemény-János(1693),Cupidó(1695),Palinodia(1695) andChariklia(1700).
The earliest edition of his collected poetical works is by Dugonics (Pressburg and Pest, 1796); the best modern selection is that of Toldy, entitledGyöngyösi István válogatott poétai munkái(Select poetical works of Stephen Gyöngyösi, 2 vols., 1864-1865).
The earliest edition of his collected poetical works is by Dugonics (Pressburg and Pest, 1796); the best modern selection is that of Toldy, entitledGyöngyösi 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 RomanArabona. 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 ofSibylle 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 theFigaroand theVie 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 theVie parisienne, and later to theRevue 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 Cœur 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 Cœur 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 dramatizeAutour du mariagewas 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 wasMademoiselle 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.γύψος, 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, theσεληνίτηςof Dioscorides, so named fromσελήνη, “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,frepresents the prism,lthe 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.).
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.
Pure gypsum is colourless or white, but it is often tinted, especially in the alabaster variety, grey, yellow or pink. Gypsum crystallizes with two molecules of water, equal to about 21% byweight, and consequently has the formula CaSO4·2H2O. By exposure to strong heat all the water may be expelled, and the substance then has the composition of anhydrite (q.v.). When the calcination, however, is conducted at such a temperature that only about 75% of the water is lost, it yields a white pulverulent substance, known as “plaster of Paris,” which may readily be caused to recombine with water, forming a hard cement. The gypsum quarries of Montmartre, in the north of Paris, were worked in Tertiary strata, rich in fossils. Gypsum is largely quarried in England for conversion into plaster of Paris, whence it is sometimes known as “plaster stone,” and since much is sent to the Staffordshire potteries for making moulds it is also termed “potter’s stone.” The chief workings are in the Keuper marls near Newark in Nottinghamshire, Fauld in Staffordshire and Chellaston in Derbyshire. It is also worked in Permian beds in Cumberland and Westmorland, and in Purbeck strata near Battle in Sussex.
Gypsum frequently occurs in association with rock-salt, having been deposited in shallow basins of salt water. Much of the calcium in sea-water exists as sulphate; and on evaporation of a drop of sea-water under the microscope this sulphate is deposited as acicular crystals of gypsum. In salt-lagoons the deposition of the gypsum is probably effected in most cases by means of micro-organisms. Waters containing sulphuretted hydrogen, on exposure to the air in the presence of limestone, may yield gypsum by the formation of sulphuric acid and its interaction with the calcium carbonate. In volcanic districts gypsum is produced by the action of sulphuric acid, resulting from the oxidation of sulphurous vapours, on lime-bearing minerals, like labradorite and augite, in the volcanic rocks: hence gypsum is common around solfataras. Again, by the oxidation of iron-pyrites and the action of the resulting sulphuric acid on limestone or on shells, gypsum may be formed; whence its origin in most clays. Gypsum is also formed in some cases by the hydration of anhydrite, the change being accompanied by an increase of volume to the extent of about 60%. Conversely gypsum may, under certain conditions, be dehydrated or reduced to anhydrite.
Some of the largest known crystals of selenite have been found in southern Utah, where they occur in huge geodes, or crystal-lined cavities, in deposits from the old salt-lakes. Fine crystals, sometimes curiously bent, occur in the Permian rocks of Friedrichroda, near Gotha, where there is a grotto called the Marienglashöhle, close to Rheinhardsbrunn. Many of the best localities for selenite are in the New Red Sandstone formation (Trias and Permian), notably the salt-mines of Hall and Hallein, near Salzburg, and of Bex in Switzerland. Excellent crystals, usually of a brownish colour arranged in groups, are often found in the brine-chambers and the launders used in salt-works. Selenite also occurs in fine crystals in the sulphur-bearing marls of Girgenti and other Sicilian localities; whilst in Britain very bold crystals are yielded by the Kimeridge clay of Shotover Hill near Oxford. Twisted crystals and rosettes of gypsum found in the Mammoth Cave, Kentucky, have been called “oulopholites” (οὖλος, “woolly”;φωλεός, “cave”).
In addition to the use of gypsum in cement-making, the mineral finds application as an agricultural agent in dressing land, and it has also been used in the manufacture of porcelain and glass. Formerly it was employed, in the form of thin cleavage-plates, for glazing windows, and seems to have been, with mica, calledlapis specularis. It is still known in Germany asMarienglasandFraueneis. Delicate cleavage-plates of gypsum are used in microscopic petrography for the determination of certain optical constants in the rock-forming minerals.