DISEASES OF THE UTERUS The uterus is functionally a very active organ ; at puberty it grows into the pear shape characteristic of sexual maturity, at the menopause it shares in the general atrophy of the reproductive organs, during each menstruation its lining membrane undergoes great modification, during pregnancy it undergoes remarkable growth, and during the puerperium it undergoes an even more remarkable process of "involution." It is subject to many dis orders : Errors in growth and development. The uterus may be congenitally absent, may remain in the infantile state (uterus foetalis), or may fail to reach full maturity (uterus pubescens) ; these conditions cause such abnormalities in the menstrual and reproductive functions as amenorrhoea, scanty menstruation, dysmenorrhoea or sterility. The uterus may be completely or partially double (uterus didelphys, uterus bicornis) . Dis placements. Normally the uterus is bent forwards (anteflexion) and turned forwards (anteversion). The chief displacements of the uterus are prolapse (downward displacement, popularly re ferred to as "falling of the womb") and retroflexion (backward bending) . Prolapse is really a protrusion or hernia of the uterus through the opening between the muscles of the pelvic floor; the uterus is protruded along, and ultimately through, the vaginal canal and there is usually an associated prolapse of the vaginal walls (q.v.). In the early stage of prolapse the uterus remains within the vagina ; in the late stage the cervix lies outside the vulva and the vagina is completely inverted (complete prolapse or pro cidentia). The symptoms are a "bearing down" feeling, great dis comfort and fatigue in walking and interference with micturition and defaecation. Prolapse is very rarely met with in women who have not borne children, and its eventual cause is the stretching and injury of the fasciae and muscles of the pelvic floor accom panying parturition ; an inborn tendency doubtless exists in many women, but in some cases too hasty delivery of the child by mid wifery forceps is blamable. The palliative treatment is by vaginal pessaries ; but cure by operation is far preferable to the permanent wearing of these uncleanly devices. The modern opera tion, which consists of a plastic repair of the pelvic floor, vaginal vault and perineum, gives the maximum of success with the mini mum of risk. Retroflexion of the uterus (bending backwards) is always combined with retroversion (rotation backwards through a transverse axis) ; it may exceptionally occur as a congenital ab normality, but is nearly always acquired as the result of child birth or abortion, or of inflammation of the Fallopian tubes. There is a great difference of opinion amongst gynaecologists as to the symptoms and effects of retroflexion, and as to the indica tions and methods of treatment. So long as the displaced uterus is healthy and is not fixed by adhesions it is, with the occasional exceptions of dyspareunia and sterility, symptomless and harm less, and requires no treatment. But when, as is sometimes the case, the uterus is in a state of chronic inflammation or subinvolu tion (q.v.), and is fixed by adhesions, it requires treatment for the relief of such symptoms as painful and profuse menstrual flow, dyspareunia, sterility or repeated abortions. Palliative treatment is by replacement and the insertion of a pessary, which is only possible when the uterus is not fixed. Curative treatment is by the operation of ventral suspension, which consists in suspending the body of the uterus or its ligaments to the anterior abdominal wall.
Inversion occurs when the uterus is turned inside out. It is only possible when the cavity is dilated, either after pregnancy or by a tumour. The greater number of cases are acute and follow immediately on delivery ; acute inversion is accompanied by much shock and haemorrhage and has a very high mortality. Chronic inversion either results from the acute variety in untreated patients who have survived, or is due to the traction of a fundal intro-uterine tumour (usually a fibroid polypus). The symptoms of chronic inversion are haemorrhage and bladder troubles, and on examination a tumour is found in the vagina. Reduction of the condition is often difficult, particularly when it has lasted for a long time.
(3). Inflammations, Acute and Chronic.—These may be divided into inflammations of the cervix and inflammations of the body of the uterus, both of which may be acute or chronic. The majority of cases are due to puerperal infection or to gonorrhoea. A sec ondary infection by the bloodstream, especially from the strep tococcus, may occur from a primary focus elsewhere. Pessaries in the vagina may cause infection, especially if not kept clean by douching and removed at intervals. Chronic inflammation of the cervix (cervicitis) is predisposed to by unhealed tears resulting from labour ; it is commonly associated with what is known as an erosion, which is a red congested annular patch of mucous mem brane. The symptoms of chronic cervicitis are a muco-purulent discharge. In acute cervicitis the cervix is red and swollen and a discharge of pus, in which the infecting germ may be discovered, pours from the cervical canal. The dangers are upward spread of the infection to the uterus, Fallopian tubes and peritoneum. The treatment of acute infections is rest in bed, vaginal douches and the application of strong antiseptics to the cervical canal. Chronic infections may be cured by the direct application of anti septics; in cases associated with unhealed tears and erosion, a cure may be effected by excision of the diseased portion. Inflammation of the body of the uterus affects chiefly the lining membrane or endometrium and is known as endometritis. Acute endometritis is usually the result of puerperal or of gonorrhoeal infection. Acute puerperal endometritis is a very serious condition, due usually to infection with the streptococcus; the infection is very liable to spread to the tubes (acute salpingitis), peritoneum (acute peritonitis) or blood stream (septicaemia). Gonorrhoeal endo metritis is always secondary to infection of the cervix; it is serious in so far as infection of the Fallopian tubes may follow. Chronic endometritis may be interstitial or glandular and results from bacterial infection. The chief types of interstitial endometritis are senile and tuberculous. Senile endometritis affects women of ter the menopause and causes a foul-smelling discharge, some times blood-stained. In such cases cancer of the body of the uterus must be excluded for the symptoms of the two conditions are closely similar. If the discharge cannot escape the uterus becomes distended with pus, forming a pyometra. Tuberculous endometritis is extremely rare and is usually due to spread from the tubes. Chronic glandular endometritis is characterized by very great thickening of the endometrium due to proliferation of the glands ; the symptom is profuse menorrhagia, and relief can be obtained only by the operation of curetting. Inflammation of the whole uterus, muscular wall as well as endometrium, is known as metritis. Acute metritis is nearly always the result of puerperal infection and the symptoms and complications are similar to those of acute endometritis. Chronic metritis is the sequel to the acute variety; the uterus is enlarged and fibrous, and the chief symptom is menorrhagia about the time of the meno pause. The menorrhagia in this case cannot be cured by curetting, because the endometrium is not thickened ; the intrauterine appli cation of radium, however, acts like a charm possibly by causing an artificial menopause.
(4). New Growths of the Uterus.—The uterus is the common est seat of new growths. (See TUMOUR.) The innocent new growths comprise adenoma, fibromyoma, adenomyoma and polypi of various kinds ; the malignant are carcinoma, sarcoma and chorionepithelioma. Adenomata usually assume a polypoid form, and occur both in the body and cervix; their symptom is uterine haemorrhage and their treatment is surgical. Fibromyomata or "fibroids" are extremely common tumours, occurring especially in women between the ages of 35 and 5o. They are believed to occur in about a 5 of women over 35 years of age, but, happily, in the great majority of cases they are small and cause no symptoms. It is doubtful if they ever originate after the menopause. They are solid round or ovoid tumours, composed of a mixture of fibrous and muscular tissue, and are usually multiple. They begin as small seedlings in the wall of the uterus and may grow to an enormous size. According to the position which they occupy in the uterine wall they are divided into intramural, subperitoneal and submucous. The two latter may assume a polypoid form. Submucous fibroids and, to a less extent, intramural fibroids give rise to severe menorrhagia, and, if this is allowed to persist, the patient may get into a dangerous state of anaemia. At the meno pause they share in the general atrophy of the uterus, and may almost disappear. Secondary changes are common in fibromyo mata, and include mucoid degeneration, cyst-f ormation, fatty changes, necrobiosis ("red degeneration"), septic infection (slough ing fibroid), and sarcomatous change.
The modes in which fibroids imperil life are haemorrhage (the commonest of all), septic infection, which is one of the most dangerous, impaction in the pelvis, twisting of the pedicle by rota tion and intestinal and urethral obstruction. During pregnancy they share in the growth of the uterus and increase greatly in size; but interference with pregnancy, such as abortion, is com mon. If growing from the cervix or lower part of the uterus they may obstruct labour and necessitate Caesarean Section (q.v.). Small symptomless fibromyomata, often discovered by accident, require no treatment, but should be watched. Fibromyomata of a certain size, or causing symptoms, require- surgical treatment, which will be either hysterectomy (removal of the uterus) or myomectomy (removing the tumour and leaving the uterus). Hysterectomy is the easier and usually the safer operation ; myo mectomy is preferable when the patient is young and it is desired to preserve the function of childbearing. Treatment by drugs or by electrical currents is, rightly, a thing of the past, but X-rays and radium have an important place. The insertion of radium into the uterus is the ideal treatment for menorrhagia due to small submucous fibroids, but is not suitable for tumours of any size. Haemorrhage from fibroids often ceases after several appli cations of X-rays; but this treatment is too uncertain in its action to compete with surgery except in cases in which an opera tion is for other reasons contraindicated.
(5) . Malignant Disease of the Uterus.—The varieties of malig nant disease met with in the uterus are carcinoma, sarcoma and chorionepithelioma malignum. The age at which women are most subject to carcinoma of the uterus is towards the decline of sexual life. Of 3,385 collected cases of cancer of the uterus 1,169 oc curred between 4o and 50, and 856 between 5o and 6o. In contra distinction to fibroid tumours it frequently arises after the meno pause. It may be divided into cancer of the body and cancer of the neck (cervix). Cancer of the neck of the uterus is almost ex clusively confined to women who have been pregnant. Predisposing causes are tears of the cervix, erosion and chronic cervicitis. The symptoms which induce women to seek medical aid are haemor rhage, foetid discharge, and, later, pain and cachexia. An unfortu nate 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 can not be too widely known that cancer of the cervix is in its early stages a purely local disease, usually curable by an operation or by radium. So important is the recognition of this fact in the saving of life that the council of the British Medical Association published in 1909 in British and Colonial medical and nursing journals a special appeal to medical practitioners, midwives and nurses. 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 women who looks quite well and who may have no pain, no wast ing, 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 :—(i) 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 accom panied 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 to touch and sight : hard nodules or definite loss of substance, extreme friability and bleed ing after slight manipulation. Cancer of the cervix may assume a proliferating type, forming the well known "cauliflower" excres cence. In the early stages, before the disease has spread to the surrounding tissues, cancer of the cervix is curable by operation. The modern operation is that perfected by the late Professor Wertheim of Vienna, and consists in removal of the whole uterus, upper third of the vagina and as much of the surrounding tissues as possible. The operation is a severe one with a primary mortality of about ten per cent, but thirty to forty per cent of early cases may be expected to remain free from recurrence for five years or more. Treatment of early or "operable" cases of cancer of the cervix by radium gives better results than operation. The latest statistics, such as those published by Heyman, of the Stockholm Radium Institute, show that about fifty per cent of early cases may be expected to remain free from recurrence for five years or more. Radium treatment demands much skill and experience in order to give such good results. A very great advantage of radium treatment is that the primary mortality is about one per cent com pared with the ten per cent or more associated with operative treatment. In advanced cases treatment by radium and X-rays must be relied upon to palliate, if not to cure. Cancer of the body of the uterus is rare before the forty-fifth year and is most fre quent after the menopause. The majority of the patients are nulliparae. The signs are fitful haemorrhages after the menopause and an offensive discharge which is usually, but not always, blood stained; the uterus is usually somewhat enlarged. Removal of the uterus (hysterectomy) is the only treatment. Chorion epithel ioma or chorionic cancer is a malignant disease with microscopic characters resembling the cells of the chorionic epithelium. It occurs in connection with recent pregnancy and particularly with the variety of abortion termed hydatidiform mole. It quickly ulcerates and infiltrates the uterine tissues, forming metastases with a rapidity unequalled by any other type of growth. Clinically it is recognized by the occurrence after pregnancy of violent haemorrhages and progressive cachexia. The, growth is usually primary in the uterus but may be so in the Fallopian tubes or in the vagina. A few cases have been recorded unconnected with preg nancy. Immediate and wide removal of the affected organ is the only treatment. Sarcoma of the uterus may occur in the body and in the cervix. It occurs at an earlier age than carcinoma. It may originate either in the wall or endometrium of the healthy uterus, or as a secondary change in a fibromyoma of the uterus. Uterine enlargement and haemorrhage are the symptoms. The differential diagnosis is microscopic. Extirpation of the uterus is the only chance of prolonging life.
Diseases of the Pelvic Peritoneum and Connective Tissue. —Women are peculiarly liable to peritoneal infections owing to the fact that the genital tract is in direct communication with the peritoneal cavity through the abdominal ostia of the Fallopian tubes. Consequently, any infection of the genital tract, by travel ling upwards to the tubes may cause peritonitis. Nearly all these infections are the result either of childbirth and abortion or of gonorrhoea. Fortunately, the pelvic peritoneum has considerable powers of resistance, and nearly all peritoneal infections of genital origin become localized to the pelvic part of the peritoneal cavity. Pelvic peritonitis or perimetritis may proceed to abscess formation the most common situation for these pus-collections being in the pouch of Douglas ; from thence they either burst into the rectum or bladder or are, more fortunately, evacuated by operation. Even if pelvic peritonitis resolves without abscess-formation it always leaves adhesions between the uterus, tubes, ovaries and the adjacent coils of intestine, resulting in abnormal position of the pelvic organs, sterility, dysmenorrhoea and other pelvic pain. General peritonitis of genital origin is comparatively rare ; it may follow puerperal infection, but seldom, if ever, is the result of gonorrhoea. Hydroperitoneum, a collection of free fluid in the peritoneal cavity, may be due to many general causes but also to papillomatous or cancerous ovarian tumours. Pelvic cellulitis or parametritis, a septic inflammation of the pelvic cellular tissue, chiefly at the bases of the broad ligaments, is usually the result of puerperal infection ; the bacteria gain entrance to the cellular tis sue through tears of the cervix uteri, such as are liable to result from difficult or instrumental labour. The symptoms are chill, rise of pulse-rate and temperature, and intrapelvic pain. On examina tion, there is tenderness and swelling on one or both sides of the pelvis beside the uterus, and the uterus becomes fixed and immov able in the exudate as if embedded in plaster of Paris. The inflam mation may undergo resolution if appropriately treated or may go on to suppuration, forming an extra-peritoneal abscess which may point in the vagina, rectum or bladder and occasionally in the groin. If the pus can be localized an incision should be made and the abscess drained.