Gynaecology

GYNAECOLOGY, the name given to that branch of medi cine which concerns the pathology and treatment of affections peculiar to the female sex.

Gynaecology is a very ancient branch of medicine. The papyrus of Ebers, one of the oldest known works on medicine (155o B.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 (46o B.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 instru ments. Writers of the Graeco-Roman period of medicine who have treated of this branch are Celsus (5o B.C.-A.D. 7), Soranus of Ephesus (A.D. 98-138) and Galen (A.D. 131-201), who devotes the sixth chapter of his work De locis affectis to gynaecological ail ments. It is evident that during this period much of the gynaeco logical work was in the hands of female healers. Martial refers to these "feminae medicae" in his epigram on Leda. These women must not be confounded with the midwives, who are always de scribed as "obstetrices." Throughout the Byzantine and Mediaeval periods of medicine, which comprise a period of more than a thousand years, gynaecology shared in the general sterility and even decadence which accompanied medical and all other branches of scientific learning; writers on gynaecology, like Oribasius (A.D. were mere compilers of the work of their predecessors and practice was bound by ancient authority and tradition. The growth of interest in diseases of women during the Renaissance period (A.D. is shown in the huge "Gynecia" or en cyclopedia of gynaecology issued by Caspar Wolf of Zurich in 1566. In the seventeenth century what has been described as the first work on operative gynaecology in the modern sense was written by Hendrik van Roonhugze (1625?) ; it contains case re ports on extra-uterine pregnancy and rupture of the uterus and the description of a scientific operation for vesico-vaginal fistula. Amongst contributions to gynaecology in the eighteenth century are William Hunter's proposal for excision of ovarian cyst and his description of retroversion of the uterus, Robert Houston'g treatment of ovarian cysts by tapping, Matthew Baillie's descrip tion of dermoid cysts of the ovary and Joseph Recamier's in vention of special specula.

Operative gynaecology, as an independent speciality, had no real existence until the first half of the nineteenth century and its founders may be said to be Ephraim MacDowell (1771-183o) of Virginia and John Marion Sims (1813-1883) of South Carolina. MacDowell performed his first ovariotomy (removal of an ovarian cyst by abdominal section) in 1809. Sims was a great surgical genius whose fame quickly spread over the whole civilized world because of his success in curing the hitherto incurable condition of vesico-vaginal fistula. In British surgery, ovariotomy became firmly established by the work of Charles Clay (1801-1893) of Manchester and Sir Spencer Wells (1818-1897) of London. Other prominent British gynaecologists of this period were Sir James J. Simpson (1811-1870) of Edinburgh, who invented the uterine sound, and Lawson Tait (1845-1899) of Birmingham, who was the pioneer in operations on the Fallopian tubes, performed the first deliberate operation for ruptured extra-uterine pregnancy, and insisted on asepsis as distinguished from antisepsis in gynae cological operations.

Menstruation

(q.v.).—At puberty, which in northern folk arrives at the age of from 13 to 15 years, the uterus and ovaries begin to undergo a complex and correlated series of changes which recur in monthly cycles and constitute the function of menstruation. Menstruation continues throughout the whole reproductive period of a woman's life, is arrested only by preg nancy, and ends at the time of the menopause, commonly known as the "change of life" (usually between 45 and 5o years of age). The double purpose of menstruation is to liberate an ovum (egg) from the ovary and to prepare the endometrium (the mucous membrane lining the uterine cavity) for the reception of such ovum should fertilization occur. The cycle of change which occurs in the ovary is known as ovulation, and that which occurs in the endometrium is chiefly concerned with the formation of the menstrual decidua. If fertilization occurs, the ovum becomes embedded in the prepared endometrium, where it continues to develop into a child, and further menstruation is arrested. If, on the other hand, fertilization does not occur, the menstrual decidua in due course becomes cast off and what is known as the menstrual flow occurs, after which the cycle of changes in the uterus and ovaries is repeated. The menstrual flow is the outward and visible sign of menstruation ; it recurs, in the absence of pregnancy, about every 28 days, lasts about 5 days, and consists of a discharge from the uterus of 4 to 6 ounces of blood mixed with fragments of menstrual decidua and with mucus from the glands of the cervix. The cycle of change which occurs in the endometrium may thus be said to consist of alternate phases of building up and breaking down. During the building up phase, which occupies about 14 days, the menstrual decidua is formed by a gradual in crease in thickness of the endometrium ; this is followed by the menstrual flow or breaking down phase, and the cycle is com pleted by a phase of rest and repair. The stimulus to the uterine cycle is provided by ovulation, for if the ovaries be removed the endometrium remains permanently in the resting phase. During ovulation an ovarian follicle (egg-chamber) ripens and ruptures, liberating an ovum ; at the site of rupture a temporary yellow body (corpus luteum) forms, and recent work has shown that the internal secretion of this body provides the chemical stimulus to the uterine changes. The time relationship between the events in the ovarian and uterine cycles is as follows : the ovarian follicle ruptures about 14 days before the onset of the menstrual flow, reaches its full development about 7 days before the flow and begins to decline after the flow has begun. There is very little evidence for the belief that the right and left ovaries ovulate alternately.

Common Disorders.

These are : (1) amenorrhoea (absence of flow), (2) menorrhagia (excessive flow), (3) epimenorrhoea (too frequent flow), (4) irregular and scanty flow, (5) dysmenor rhoea (painful flow) . Amenorrhoea may arise from physiological causes, such as pregnancy, lactation, the menopause. The onset of the first menstrual flow may be delayed beyond the usual age, but if menstruation is delayed beyond the age of 17 or 18 medical advice should be sought, as there may be some developmental error in the uterus or vagina and the sooner this is discovered the better. Amenorrhoea of pathological origin may be due to error in growth or development of the reproductive organs, or to constitutional disease. Under developmental errors come those cases where menstruation occurs but the escape of menstrual fluid is prevented by the presence of a membrane obstructing the vaginal orifice (so called "imperforate hymen") or even by the absence of the vagina or by imperforation of the cervix uteri— ("concealed menstruation"). The blood accumulates in the vagina or uterus, or both, and forms a swelling which gradually becomes larger. The uterus may fail to develop beyond the infantile state or may be completely absent, and in the latter case the amenor rhoea is permanent. Amongst constitutional causes may be men tioned chlorosis, secondary anaemia, tuberculosis, mental shock and strain, acute illness, and defective function of the thyroid or pituitary glands; in most of these the amenorrhoea is usually temporary. The treatment of amenorrhoea depends on the cause; in case of temporary amenorrhoea due to constitutional causes the flow can often be re-established by measures directed to im prove the general health. It should be noted that menstruation (i.e., ovulation and the formation of menstrual decidua) may occur with absence of menstrual flow, otherwise it is not possible to account for the occurrence of pregnancy during a period of amenorrhoea—a not uncommon event during the amenorrhoea of lactation.

Menorrhagia signifies excessive bleeding at the time of the menstrual flow, but no irregular bleeding during the interval be tween the flows. Amongst local causes are fibromyomata of the uterus, uterine polypi, excessive thickness of the endometrium, fibrosis and chronic subinvolution of the uterus, inflammation of the Fallopian tubes ; amongst the many general causes are (a) diseases associated with plethora, such as chronic cardio-vascular disease, chronic renal disease (b) primary blood diseases, such as pernicious anaemia, leukaemia, purpura and haemophilia, (c) endocrinous diseases, especially hypo- and hyperthyroidism (d) at puberty and again at the menopause there may be, for a time, excessive menstrual haemorrhage; but women should be warned that medical advice should be sought for haemorrhage at the time of the menopause as there may be a new growth of the uterus.

liregular haemorrhage independent of menstruation is always symptomatic of uterine disease, and when occurring after the age of 3o, and especially after the menopause, is often significant of cancer of the uterus. Irregular haemorrhage during early preg nancy means either threatened abortion or extra-uterine gestation. The treatment of any form of haemorrhage from the uterus de pends on the cause and demands careful diagnosis. Amongst drugs which relieve certain forms of haemorrhage are ergot, pituitary extract, ovarian extract, calcium salts and parathyroid gland. The treatment of new growths and other local conditions is considered under the appropriate sections.

Too frequent or irregular menstruation is not uncommon and, so long as the flow is not profuse, has no particular significance; since the ovary is the pacemaker of the uterus in menstruation, the cause probably lies in irregular ovulation or other disturbed function of the ovary.

There are two varieties of menstrual pain or dysmenorrhoea (a) spasmodic (b) congestive. Spasmodic dysmenorrhoea is due to painful contractions of the uterus and the pain is severe and cramplike, beginning with the onset of the flow and lasting a few hours or a day; the pain is believed to be associated with the shedding of the menstrual decidua and the entire membrane can of ten be discovered in the discharge. In a few cases the uterus is poorly developed, but usually no abnormality can be detected. The treatment consists of rest, hot baths, and such anti-spasmodic drugs as phenazone, phenacetin, aspirin, atropine. If this fails the little operation of dilatation of the cervix often cures. Cases which arise in later life are usually due to a submucous fibro myoma of the uterus ; the treatment consists in removal of the tumour. Congestive dysmenorrhoea is a severe aching which be gins about a week before, and is relieved by, the flow ; it is due to chronic inflammatory disease of the Fallopian tubes or of the uterus, or to uterine fibromyomata. The treatment consists in the surgical removal of the cause.

Infections of the Reproductive Organs.

About sixty per cent of infections are puerperal (after childbirth or abortion), about twenty per cent are gonorrhoeal, and the remainder are fortuitous infections, often secondary to a primary focus else where, such as in the bowel (appendicitis, diverticulitis), the tonsils or the teeth; about five per cent of infections are due to the tubercle bacillus. In most puerperal infections, and in all gonorrhoeal, the infection is ascending, i.e., the infection begins in the vulva, vagina, or cervix uteri and ascends upwards to the uterus, Fallopian tubes and peritoneum. In other cases the bacteria are carried to the organs by the blood-stream (haemato genous infection). The infection may remain localized to the various organs, or the bacteria may gain the blood-stream in which they may multiply and cause the very grave condition known as septicaemia. (See SEPSIS.) The infective diseases which may be caused are vulvitis, vaginitis, cervicitis, endometritis, salpin gitis, ovaritis and peritonitis; usually, especially in puerperal and gonorrhoeal infections, the condition is widespread. Syphilitic infection of the reproductive organs is considered elsewhere. (See