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
