prolapse, or any condition interfering with the circulation. The symptoms comprise local discomfort and sometimes dysmenorrhoea, leucorrhoea or menorrhagia. When the elongation occurs in the cervical portion the only possible treatment is amputation of the cervix. Atrophy of the uterus is normal after the menopause. It may follow the removal of the tubes and ovaries. Some constitutional diseases produce the same result, as tuberculosis, chlorosis, chronic morphinism and certain diseases of the central nervous system.
(c) Injuries and Diseases resultant from Pregnancy.—The most frequent of these injuries is laceration of the cervix uteri, which is frequent in precipitate labour. Once the cervix is torn the raw surfaces become covered by granulations and later by cicatricial tissue, but as a rule they do not unite. The torn lips may become unhealthy, and the congestion and oedema spread to the body of the uterus. A lacerated cervix does not usually give rise to symptoms; these depend on the accompanying endometritis, and include leucorrhoea, aching and a feeling of weight. Lacerations are to be felt digitally. As lacerations predispose to abortion the operation of trachelorraphy or repair of the cervix is indicated. Perforation of the uterus may occur from the use of the sound in diseased conditions of the uterine walls. Superinvolution means premature atrophy following parturition. Subinvolution is a condition in which the uterus fails to return to its normal size and remains enlarged. Retention of the products of conception may cause irregular haemorrhages and may lead to a diagnosis of tumour. The uterus should be carefully explored.
(d) Inflammations Acute and Chronic.—The mucous membrane lining the cervical canal and body of the uterus is called the endometrium. Acute inflammation or endometritis may attack it. The chief causes are sepsis following labour or abortion, extension of a gonorrhoeal vaginitis, or gangrene or infection of a uterine myoma. The puerperal endometritis following labour is an avoidable disease due to lack of scrupulous aseptic precautions.
Gonorrhoeal endometritis is an acute form associated with copious purulent discharge and well-marked constitutional disturbance. The temperature ranges from 99° to 105° F., associated with pelvic pain, and rigors are not uncommon. The tendency is to recovery with more or less protracted convalescence. The most serious complications are extension of the disease and later sterility. Rest in bed and intrauterine irrigation, followed by the introduction of iodoform pencils into the uterine cavity, should be resorted to, while pain is relieved by hot fomentations and sitz baths. Chronic endometritis may be the sequela of the acute form, or may be septic in origin, or the result of chronic congestion, acute retroflection or subinvolution following delivery or abortion. The varieties are glandular, interstitial, haemorrhagic and senile. The symptoms are disturbance of the menstrual function, headache, pain and pelvic discomfort, and more or less profuse thick leucorrhoeal discharge. The treatment consists in attention to the general health, with suitable laxatives and local injections, and in obstinate cases curettage is the most effectual measure. The disease is frequently associated with adenomatous disease of the cervix, formerly called erosion. In this disease there is a new formation of glandular elements, which enlarge and multiply, forming a soft velvety areola dotted with pink spots. This was formerly erroneously termed ulceration. The cause is unknown. It occurs in virgins as well as in mothers, but it often accompanies lacerations of the cervix. The symptoms are indefinite pain and leucorrhoea. The condition is visible on inspection with a speculum. The treatment is swabbing with iodized phenol or curettage. The body of the uterus may also be the seat of adenomatous disease. Tuberculosis may attack the uterus; this usually forms part of a general tuberculosis.
(e) New Growths in the Uterus.—The uterus is the most common seat of new growths. From the researches of von Gurlt, compiled from the Vienna Hospital Reports, embracing 15,880 cases of tumour, females exceed males in the proportion of seven to three, and of this large majority uterine growths account for 25%. When we consider its periodic monthly engorgements and the alternate hypertrophy and involution it undergoes in connexion with pregnancy, we can anticipate the special proneness of the uterus to new growths. Tumours of the uterus are divided into benign and malignant. The benign tumours known as fibroids or myomata are very common. They are stated by Bayle to occur in 20% of women over 35 years of age, but happily in a great number of cases they are small and give rise to no symptoms. They are definitely associated with the period of sexual activity and occur more frequently in married women than in single, in the proportion of two to one (Winckel). It is doubtful if they ever originate after the menopause. Indeed if uncomplicated by changes in them they share in the general atrophy of the sexual organs which then takes place. They are divided according to their position in the tissues into intramural, subserous and submucous (the last when it has a pedicle forms a polypus), or as to the part of the uterus in which they develop into fibroids of the cervix and fibroids of the body. Intramural and submucous fibroids give rise to haemorrhage. The menses may be so increased that the patient is scarcely ever free from haemorrhage. The pressure of the growth may cause dysmenorrhoea, or pressure on the bladder and rectum may cause dysuria, retention or rectal tenesmus. The uterus may be displaced by the weight of the tumour. Secondary changes take place in fibroids, such as mucous degeneration, fatty metamorphosis, calcification, septic infection (sloughing fibroid) and malignant (sarcomatous) degeneration.
The modes in which fibroids imperil life are haemorrhage (the commonest of all), septic infection, which is one of the most dangerous, impaction when it fits the true pelvis so tightly that the tumour cannot rise, twisting of the pedicle by rotation, leading to sloughing and intestinal and urinary obstruction. When fibroids are complicated by pregnancy, impaction and consequent abortion may take place, or a cervical myoma may offer a mechanical obstacle to delivery or lead to serious post partem haemorrhage. In the treatment of fibroids various drugs (ergot, hamamelis, hydrastis canadensis) may be tried to control the haemorrhage, and repose and the injection of hot water (120° F.) are sometimes successful, together with electrical treatment. Surgical measures are needed, however, in severe recurrent haemorrhage, intestinal obstruction, sloughing and the co-existence of pregnancy. An endeavour must be made if possible to enucleate the fibroid, or hysterectomy (removal of the uterus) may be required. The operation of removal of the ovaries to precipitate the menopause has fallen into disuse.
(f) Malignant Disease of the Uterus.—The varieties of malignant disease met with in the uterus are sarcoma, carcinoma and chorion-epithelioma malignum. Sarcomata may occur in the body and in the neck. They occur at an earlier age than carcinomata. Marked enlargement and haemorrhage are the symptoms. The differential diagnosis is microscopic. Extirpation of the uterus is the only chance of prolonging life. The age at which women are most subject to carcinoma (cancer) of the uterus is towards the decline of sexual life. Of 3385 collected cases of cancer of the uterus 1169 occurred between 40 and 50, and 856 between 50 and 60. In contradistinction to fibroid tumours it frequently arises after the menopause. It may be divided into cancer of the body and cancer of the neck (cervix). Cancer of the neck of the uterus is almost exclusively confined to women who have been pregnant (Bland-Sutton). Predisposing causes may be injuries during delivery. The symptoms which induce women to seek medical aid are haemorrhage, foetid discharge, and later pain and cachexia. An unfortunate belief amongst the public that the menopause is associated with irregular bleeding and offensive discharges has prevented many women from seeking medical advice until too late. It cannot be too widely understood that cancer of the cervix is in its early stages a purely local disease, and if removed in this stage usually results in cure. So important is the recognition of this fact in the saving of human life that at the meeting of the British Medical Association in April 1909 the council issued for publication a special appeal to medical practitioners, midwives and nurses, and directed it to be published in British and colonial medical and nursing journals. It will be useful to quote here a part of the appeal directed to midwives and nurses: “Cancer may occur at any age and in a woman who looks quite well, and who may have no pain, no wasting, no foul discharge and no profuse bleeding. To wait for pain, wasting, foul discharge or profuse bleeding is to throw away the chance of successful treatment. The early symptoms of cancer of the womb are:—(1) bleeding which occurs after the change of life, (2) bleeding after sexual intercourse or after a vaginal douche, (3) bleeding, slight or abundant, even in young women, if occurring between the usual monthly periods, and especially when accompanied by a bad-smelling or watery blood-tinged discharge, (4) thin watery discharge occurring at any age.” On examination the cervix presents certain characteristic signs, though these may be modified according to the variety of cancer present. Hard nodules or definite loss of substance, extreme friability and bleeding after slight manipulation, are suspicious. Epithelial cancer of the cervix may assume a proliferating ulcerative type, forming the well-known “cauliflower” excrescence. The treatment of cancer of the cervix is free removal at the earliest possible moment. Cancer of the body of the uterus is rare before the 45th year. It is most frequent at or subsequent to the menopause. The majority of the patients are nulliparae (Bland-Sutton). The signs are fitful haemorrhages after the menopause, followed by profuse and offensive discharges. The uterus on examination often feels enlarged. The diagnosis being made, hysterectomy (removal of the uterus) is the only treatment. Cancer of the body of the uterus may complicate fibroids. Chorion-epithelioma malignum (deciduoma) was first described in 1889 by Sänger and Pfeiffer. It is a malignant disease presenting microscopic characters resembling decidual tissue. It occurs in connexion with recent pregnancy, and particularly with the variety of abortion termed hydatid mole. In many cases it destroys life with a rapidity unequalled by any other kind of growth. It quickly ulcerates and infiltrates the uterine tissues, forming metastatic growths in the lung and vagina. Clinically it is recognized by the occurrence after pregnancy of violent haemorrhages, progressive cachexia and fever with rigors. Recent suggestions have been made as to chorion-epithelioma being the result of pathological changes in the lutein tissue of the ovary. The growth is usually primary in the uterus, but may be so in the Fallopian tubes and in the vagina. A few cases have been recorded unconnected with pregnancy. The virulence of chorion-epithelioma varies, but in the present state of our knowledge immediate removal of the primary growth along with the affected organ is the only treatment.
Diseases of the Fallopian Tubes.—The Fallopian tubes or oviducts
