A text-book of gynecology

Preface

In preparing this volume the limited time of the overcrowded medical student has been taken into consideration. The facts have been stated briefly and an attempt has been made to put them clearly. Many subjects that are given space in text-books on gynecology, but which belong to general surgery, have been omitted. Many rare diseases are treated very briefly. The greater amount of space is given to diseases that are common and with which it is essential that the student should be familiar. It is believed that enough has been given on each subject to constitute a thorough presentation of it.

I am indebted to Mr. Herman Schapiro for the photographs of the gross pathological specimens and for the photomicrographs. These gross specimens, and the slides from which the photomicrographs were made, are a part of the material which I have been using for several years in teaching diagnosis and living gynecological pathology. I am indebted to Mr. W. Starr Gebhart, Jr., and to Dr. J. A. Rippert for the line drawings. Dr. G. Alvin Strauss and Dr. A. Samuels gave material assistance in examining the preliminary copy and noting omissions of fact.

William S. Gardner.

6 W. Freston Street,

Baltimore, Md.

Chapter III

Anatomy — Adhesions of the labia majora — Skin infections — Gonorrheal vulvitis — Follicular vulvitis — Phlegmonous vulvitis — Diphtheritic vulvitis — Catarrhal vulvitis — Pruritus — Hyperesthesia of the vulva — Chancre — Chancroid — Kraurosis — Varicocele — Hematoma — Epithelioma — Elephantiasis — Inguinal hernia — Hydrocele — Fibroids — Venereal warts — Injuries to the vulva — Infections of Bartholin's glands — Abscess of the vulvo-vaginal gland ; Retention cyst of the vulvo-vaginal gland — Imperforate hymen

19-37

Chapter IV

Anatomy — Gonorrheal vaginitis — Follicular vaginitis — Diphtheritic vaginitis — Aphthous vaginitis — Tuberculosis of the vagina — Paravaginitis — Adhesive vaginitis — Vaginitis in children — Stenosis of the vagina — Atresia of the vagina — Vaginal cysts — Solid tumors of the vagina: Fibroids; Carcinoma; Sarcoma; Chorio-epithelioma — Vaginismus — Dysparunia

38-47

CONTENTS CHAPTER V

Pages

Anatomy — Laceration of the perineum — Rectocele — Cystocele —

Recto-vaginal fistula 48-67

CHAPTER VI URINARY FISTULjE

Varieties — Etiology — Urethro-vaginal fistula — Vesico-vaginal fistula — Vesico-utero-vaginal fistula — Vesico-uterine fistula — Uretero-vaginal fistula 68-75

Chapter VII Diseases Of The Urethra And Bladder

Urethral caruncle — Urethritis — Stricture of the urethra— Sub-urethral abscess — Prolapse of the urethra — Over-distention of the urethra — Urethrocele — Vesico-urethral fissure — Exstrophy of the bladder — Cystitis — Vesical calculus 76-89

Chapter XIX Solid Ovarian Tumors : Parovarian Cysts, Tumors Of The Broad Ligaments

Pages Solid tumors of the ovary : Fibromata ; Papillomata ; Carcinomata ;

Sarcomata — Parovarian cysts — Solid tumors of the broad ligament — Varicocele of the broad ligament 245-251

Chapter XX

Abdominal operations : Place of operation; Time of operation ; Preparation of the patient ; Preparation of instruments, etc. ; Preparation of the operator and assistants ; Anesthesia ; Position of the patient ; Incision ; Drainage ; Closure of the abdominal wound ; Dressing of wound — Vaginal operations : Preparation ; Posterior vaginal section ; Anterior vaginal section ; Dilatation of the cervix ; Curettage — Local treatment : Douches, Tampons, Applications . 252-263

Chapter XXI Post-operative Complications

Shock — Hemorrhage — Vomiting — Distended intestines — Infection

of the abdominal wound — Fecal fistulse — Hernia . . . . . 264-267

Chapter XXII Post-operative Treatment

Abdominal operations : Position of the patient ; Diet ; Removal of stitches ; Time in bed — Vaginal operations : Repair of vaginal outlet ; Curettement ; Vaginal celiotomy 268-271

LIST OF ILLUSTRATIONS

Figure

Page

1. Bimanual examination 7

2. External genitals *9

QO

3. Follicular vulvitis

4. Epithelioma of the vulva 29

5. Epithelioma of the vulva. (Photomicrograph) 30

6. Elephantiasis of the vulva 31

7. Elephantiasis. (Photomicrograph) 32

8. Venereal warts "3

9. Venereal warts. (Photomicrograph) 34

10. Abscess of Bartholin's gland 36

11. Normal vaginal epithelium. (Photomicrograph) 39

12. Vaginal cysts 45

13. Relaxed vaginal outlet 49

14. Complete tear of the perineum 49

15. Flap-splitting operation for laceration of the perineum. First step . 53

16. Flap-splitting operation. Second step 54

17. Flap-splitting operation. Third step 55

18. Flap-splitting operation. Fourth step 56

19. Emmet's operation for laceration of the perineum. First step ... 57

20. Emmet's operation. Second step 58

21. Emmet's operation. Third step 59

22. Hegar's operation for laceration of the perineum 60

23. Operation for repair of the sphincter ani. First step 61

24. Operation for repair of the sphincter ani. Second step 62

25. Cystocele and rectocele 63

26. Thickened vaginal epithelium. (Photomicrograph) 64

27. Repair of cystocele. First step 65

28. Repair of cystocele. Second step 65

29. Repair of cystocele. Third step 66

30. Repair of cystocele. Fourth step 66

31. Diagram showing location of urinary fistula; 69

32. Repair of vesico-vaginal fistula. First step 72

33. Repair of vesico-vaginal fistula. Second step 73

34. Urethral caruncle 76

35. Urethral caruncle. (Photomicrograph) 77

36. Post-menstrual endometrium. (Photomicrograph) 91 xii LIST OF ILLUSTRATIONS

Figure Page

37. Pie-menstrual endometrium. (Photomicrograph) 92

38. Normal cervical glands. (Photomicrograph) 93

39. Blood supply to the uterus 94

40. Lymphatics of the uterus 95

41. Normal position of the uterus . . 97

42. Anteflexion of the uterus 100

43. Retroversion of the uterus 102

44. Retroflexion of the uterus 103

45. Manual replacement of retrodisplaced uterus. First step . . . . 104

46. Manual replacement of retrodisplaced uterus. Second step . . . 105

47. Manual replacement of retrodisplaced uterus. Third step .... 106

48. A pessary in position 107

49. Round ligament suspension of the uterus 109

50. Ventral suspension 110

51. Prolapse of the uterus Ill

52. Thickened epithelium on a prolapsed cervix. (Photomicrograph) . 112

53. Operation for prolapse of the uterus. First step 114

54. Operation for prolapse of the uterus. Second step 115

55. Laceration of the cervix 122

56. Repair of laceration of the cervix 123

57. Amputation of the cervix. First step 123

58. Amputation of the cervix. Second step 124

59. Amputation of the cervix. Third step 124

60. Amputation of the cervix. Fourth step 125

61. Amputation of the cervix. Fifth step 126

62. Erosion of the cervix 128

63. Erosion of the cervix. (Photomicrograph) 129

64. Cystic degeneration of the cervix 130

65. Endometritis. (Photomicrograph) 135

66. Endometritis. (Photomicrograph) 136

67. Endometritis. (Photomicrograph) 137

68. Tuberculous endometritis. (Photomicrograph) 138

69. Adenoma. (Photomicrograph) 141

70. Epithelioma of the cervix 142

71. Epithelioma of the cervix 143

72. Epithelioma of the cervix. (Photomicrograph) 144

73. Epithelioma of the cervix. (Photomicrograph) 145

74. Epithelioma of the cervix. (Photomicrograph) 146

75. Epithelioma of the cervix. (Photomicrograph) 147

76. Adeno-carcinoma of the cervix. (Photomicrograph) 118

77. Adeno-carcinoma of the body of the uterus 149

78. Adeno-carcinoma of the body of the uterus. (Photomicrograph) . 150

79. Vaginal hysterectomy. First step 157

80. Vaginal hysterectomy. Second step 157

81. Vaginal hysterectomy. Third step 158

LIST OF ILLUSTKATIONS xiii

Figure Page

82. Vaginal hysterectomy. Fourth step 158

83. Chorionic villi. (Photomicrograph) 164

84. Chorio-epithelioma. (Photomicrograph) 165

85. Multiple fibroids 168

86. Submucous fibroid 169

87. Fibroid polypus 170

88. Subperitoneal fibroid 171

89. Fibromyoma. (Photomicrograph) 172

90. Adeno-fibromyoma. (Photomicrograph) 173

91. Fibroid undergoing cystic degeneration 174

92. Fibro sarcoma. (Photomicrograph) 175

93. Outline of abdomen containing a large fibroid 180

94. Supravaginal hysterectomy. First step 184

95. Supravaginal hysterectomy. Second step 185

96. Supravaginal hysterectomy. Third step 186

97. Myomectomy 187

98. Uterine end of Fallopian tube. (Photomicrograph) 1S9

99. Middle of Fallopian tube. (Photomicrograph) ....... 190

100. Fimbriated extremity of Fallopian tube. (Photomicrograph) . . 19i

102. Purulent salpingitis. (Photomicrograph) 192

103. Interstitial salpingitis. (Photomicrograph) 194

104. Hydrosalpinx 195

105. Hydrosalpinx. (Photomicrograph) 196

106. Tubo-ovarian abscess 197

107. Posterior vaginal section. First step 198

108. Posterior vaginal section. Second step 199

109. Removal of infected tube 200

110. Removal of infected tube and ovary 201

111. Posterior vaginal drain 203

112. Tuberculous salpingitis 205

113. Tuberculous salpingitis. (Photomicrograph) 206

114. Diagram showing various locations of extrauterine pregnancy in the

tube 211

116. Tubal abortion 213

117. Cortex of a normal ovary. (Photomicrograph) ....... 219

IIS. Corpus luteum. (Photomicrograph) 220

119. Infected ovary. (Photomicrograph) 221

120. Operation for prolapsed ovary 226

121. Multilocular ovarian cyst 228

122. Wall of multilocular ovarian cyst. (Photomicrograph) .... 229

123. Papillomatous ovarian cyst 230

124. Wall of papillomatous ovarian cyst. (Photomicrograph)- • ■ • 23]

125. Ovarian dermoid 232 xiv LIST OF ILLUSTRATIONS

Figure Page

126. Outline of abdomen containing an ovarian tumor 234

127. Outline of abdomen with ascites 236

128. Carcinoma of the ovary developing from papillomatous cyst. (Pho-

tomicrograph) 239

129. Carcinoma of the ovary developing from an adeno-cystoua. (Pho-

tomicrograph) 240

130. Sarcoma of the ovary 241

131. Ovarian fibroid 245

132. Solid ovarian carcinoma 246

133. Solid ovarian carcinoma. (Photomicrograph) 247

134. The parovarium 248

135. Parovarian cyst 249

136. Variocele of the broad ligament 250

137. Closure of abdominal wound 257

138. Dressing of abdominal wound 258

A TEXT-BOOK OF GYNECOLOGY

Chapter I

Clinical Record. — Too much stress cannot be laid upon the necessity of taking a careful clinical record of each patient. The record should include a history of the patient's symptoms as given by her in reply to certain routine inquiries and to additional questions asked to develop fully any particular complaint that may be noted. The patient should then state in her own way any further facts that have a bearing upon her condition. The record must be brief but must cover fully a few essential points. There is rarely any occasion to go into the family history. The more important points to be covered in the record are indicated in the following outline.

Date. Name. Age.

Besidence. By whom referred.

Appetite. Bowels. Defecation.

Micturition.

Previous illnesses and operations.

Gonorrhea. Syphilis.

Pregnancies.

Menses.

General complaints.

Physical examination.

The name of the patient is wanted as a matter of identification.

The age is taken because it has a direct bearing on the sum of probabilities that make up the diagnosis, since some diseases are much more common at certain periods of life than at others.

The record of the eesidence is kept principally as a part of the identification, but it often will help directly by throwing light on the social status of the patient.

Inquiry into the condition of the appetite and bowels should be made because, no matter what the local condition is, the nutrition of the patient is always a matter of importance and must be looked after.

It should be ascertained whether defecation is painful or not; if it is painful, whether the pain is present only during defecation or continues for some time afterwards and how long the symptom has been present.

In reference to micturition, it is important to know whether it is too frequent or painful, or both, and if so, how long these symptoms have been present.

In recording the previous illnesses, it is of no advantage to go into the history of the diseases of childhood, or even those of later life, except those illnesses that had some predominant pelvic or abdominal symptoms. The most important of these are the infections after labors or after miscarriages. Unfortunately the history that most patients give of previous operations is very vague, but in cases where abdominal operations have been performed it is of great assistance to know accurately what has been done.

As a rule no valuable information is obtained by asking directly if the patient has had gonorrhea or syphilis. It is much better to make inquiry as to the history of the symptoms that may have been due to these diseases. If the patient has had gonorrhea, there will usually be a history of a profuse vaginal discharge associated with

ABDOMINAL EXAMINATION 3

burning micturition, the date of which can usually be fixed. If she has had syphilis, there will usually be a history of a skin eruption, falling hair, or repeated sore throat.

It is hardly necessary to go into the history in detail of each one of the patient's pregnancies. The number of labors at full term and the number of miscarriages should be noted, and what is of great importance is to know whether the last pregnancy ended as a full term labor or as a miscarriage, the date of termination, and whether it was followed by any sjrmptoms of infection.

In noting the menstrual history the first point is the date of the last period. If there has been anything irregular about this last period, then the dates of two or three previous periods should be noted. Never accept the patient's statement that she is always regular; get the exact dates. Note the frequency, duration, and relative quantity of blood lost. If pain is present during the period, determine what the time relation is between the pain and the flow, what the character of the pain is, and how long the patient has suffered from it.

When these points have been noted, the patient should be asked to state her definite complaints. The location and character of any pain and the length of time she has suffered from it should be recorded in detail.

Abdominal Examination. — In beginning the physical examination, it is best to start with the examination of the abdomen. The bladder and rectum should be emptied and the patient put in the dorsal position with the limbs extended. All coverings between the ensiform appendix and the symphysis should be removed.

Inspection, palpation, percussion, and auscultation are all employed.

Inspection. — By inspection the size and general eontour of the abdomen is noted. "When there is an enlargement, the shape, the point of greatest prominence, and the extent of the movements of the abdominal wall during respiration are noted. Striae indicating previous distentions, pigmentation, and enlarged veins should be looked for. In pregnancy the fetal movements can often be seen. Cicatrices, the result of previous operations, should be noted.

Palpatio^. — By palpation, tumors, displaced organs, points of tenderness, and areas of muscular rigidity are discovered. The hands of the examiner should be warm and he should proceed slowly and gently, beginning by preference over that portion of the abdomen where nothing abnormal is likely to be found. If this is done, by the time the portion of the abdomen is approached which is suspected to be abnormal it will be found that the patient's timidity, and much of the associated muscular rigidity, will have disappeared and the examination can be made much more easily.

After going over the abdomen in a general way special attention should be directed to the regions of the appendix, the gall-bladder, the kidneys, and the ovaries. The most common location of the appendix is just below the middle of a line extending from the umbilicus to the anterior superior spine of the right ilium. The common signs of disease of the appendix are tenderness, elicited by deep pressure and rigidity of the muscles over this area. In exceptional cases a mass can be palpated. Disease of the gall-bladder is indicated by tenderness and muscular rigidity over its region, and particularly by the inability of the patient to take a full breath when the fingers are pressed firmly under the edge of the ribs just to the right of the median line. The thickness and tension of the abdominal walls should be noted.

Palpation is very much facilitated if the patient is in-

VAGINAL EXAMINATION 5

structed to breathe deeply. On expiration the abdominal wall relaxes and the deeper structures in the abdomen can be palpated without making undue pressure. If a tumor is present, some idea of its size, origin, mobility, and density can be made out. Fluctuation can be felt in cystic tumors, but the wave produced by tapping the tumor on one side while one hand is held against the opposite side can be felt clearly only in exceptional cases. The value of this sign has been exaggerated. The beginner frequently confuses the true fluctuation wave with the impulse transmitted by the abdominal wall.

Percussion. — By percussion the tympanitic and dull areas are mapped out and their relation to each other and to any palpable tumor are noted. It is very important to observe whether the relation of these areas to each other change with the change of the position of the patient.

Auscultation. — The most important sign elicited by auscultation is the presence or absence of the fetal heart sounds.

Vaginal Examination. — "When the abdominal examination is completed the next step is the examination of the external genitals and the pelvic contents by way of the vagina. This is done by inspection, the simple vaginal touch, and by the bimanual examination. Before attempting a vaginal examination the patient should be put in the dorsal position with the legs flexed and separated, but the thighs must not be pressed upon the abdomen. A simple way to get a good position is to flex and separate the knees but keep the feet on a level with the back. The bladder must be empty.

Inspection. — Practically all the ordinary diseases of the vulva can be diagnosed by inspection. By separating the labia any pathological condition of the vestibule and vaginal orifice is exposed and the condition of the perineum and the color and position of the anterior and posterior vaginal walls near the outlet are noted.

Simple Vaginal. Touch. — By simple vaginal touch is meant the examination by the introduction of one or two fingers into the vagina and the palpation of the vaginal walls and cervix without any counter pressure. By this method pathological conditions of the vaginal portion of the cervix, of the vaginal walls, or any pelvic growths that displace the vaginal walls, can be detected.

Bimanual Examination. — One or two fingers are introduced into the vagina while counter pressure is made over the lower segment of the abdomen by the other hand. The first thing to ascertain is the position of the uterus. "When the uterus is in the normal position, if the fingers in the vagina are placed under the cervix and then elevated the fundus can be felt by the external hand just above the symphysis (Fig. 1). The fingers in the vagina can then be slipped forward and the body of the uterus grasped between the fingers of the internal and external hands. In this way its size, shape, and consistence can be determined. When the body of the uterus is not found in the normal position, it should be sought for first posteriorly and then laterally. The broad ligaments, the tubes, and the ovaries are then palpated. This can be done very readily after the uterus has been located by slipping the fingers of both hands, between which the uterus is lying, either to the right or to the left. By this movement the broad ligament and everything attached to it must come between the opposed fingers.

Complete anesthesia facilitates all bimanual examinations and is absolutely essential in many cases. The anesthetic is called for not to relieve pain produced by the examination, but to secure muscular relaxation.

Instruments Used in Examination. — During the examina-

INSTRUMENTS USED IN EXAMINATION 7

tion of a patient some of the following instruments are frequently needed : catheter, speculum, tenaculum, dressing forceps, bullet forceps, dilator, curette, scissors, needle, needle holder, and suture material.

The most often used of these is the catheter. When-

Fig. 1. — Bimanual Examination. The uterus is elevated by the fingers under the cervix until the fundus can be felt through the abdominal wall above the pubes.

ever a bimanual examination is made it must be assured that the bladder is empty, and the most certain way to empty it is to pass a catheter.

For office purposes the self-retaining, trivalve, Nott's speculum is one of the most satisfactory, but for general usefulness there is no speculum superior to the perineal retractor of Simon. The blades of this speculum are made in different sizes, and the blade can be selected which is best suited to the case.

It is often necessary to draw the uterus down, and when the patient is not under an anesthetic this should be done with a tenaculum. If it is introduced well into the cervical canal a good hold can be taken without giving any pain. A simple rule for the use of the tenaculum without giving the patient discomfort is to avoid mucous membrane that is covered with squamous epithelium.

The dressing forceps are used to wipe away any discharge and clear the field.

To carry the examination beyond this point it is usually necessary to use an anesthetic. The patient should be in the lithotomy position, with the hips drawn well over the end of the table. Bullet forceps or a small volsellum are used to draw the uterus down, because stronger traction can be made with them than with a tenaculum, and it is not necessary to avoid the sensitive areas.

For rapid dilatation of the cervix some pattern of the parallel-bar dilator is preferable. It is not necessary to make a very wide dilatation.

The curette for obtaining material for microscopical examination from the cavity of the uterus or the cervix should be sharp, and so made that the edge will strike at right angles to the surface to be curetted. The material should be removed in as large fragments as possible.

When a piece of the cervix is required, a small triangular section can be removed with scissors and the wound closed with one or two sutures.

The uterine sound is purposely omitted from the list of instruments ordinarily used in making examinations, for the reason that the small amount of information to be obtained from it is more than counterbalanced by the

POSITIONS 9

harm resulting from its unskilful use. The man who cannot make a diagnosis of pregnancy at the eighth week by bimanual examination cannot use a sound with reasonable safety. The man who can make a diagnosis of pregnancy at the eighth week very rarely has occasion to resort to the sound.

Before operation the urine should be examined in all cases. It is also well to make a blood examination as a routine measure ; but it is especially indicated if the patient has a temperature above normal or is anemic.

Positions. — For examination or for operation the patient may be placed in the following positions:

First Dorsal Position. — In this position the patient lies on a straight table, the limbs and body on the same plane. The patient is placed in this position in making routine abdominal examinations and in doing many abdominal operations.

Second Dorsal Position. — In this position the hips and back of the patient are on a level table. The knees are flexed and separated. The feet are kept on the same level with the hips and back. This position is used for the examinations of the external genitals and in bimanual examinations.

Lithotomy Position. — In this position the patient lies on the back, the legs are flexed on the thighs, and the thighs upon the abdomen. This position is used for all vaginal operations. With the patient in the same position except with the hips very much elevated the cystoscope is used.

Trendelenburg Position. — In this position the patient lies on the back with the limbs extended. The pelvis is elevated while the knees are slightly or not at all flexed. This position is used in nearly all pelvic operations that are done through the abdominal wall. The position assists in keeping the intestines out of the way and in exposing the pelvic .contents to the view of the operator.

Sims Position. — In the Sims, or left lateral position the patient lies on the left side with the left arm drawn behind. The knees are flexed and the right knee is drawn a little forward and over the left one. Many of the plastic operations about the vagina and cervix can be done in this position, but the majority of operators have abandoned it for the simpler lithotomy position.

Knee-Chest Position. — In this position the patient rests with the chest on the table. The knees are drawn up under her with the thighs kept at right angles to the surface of the table. This position is used principally for assisting in the readjustment of retrodisplacements of the uterus, to temporarily relieve pelvic congestion, and in exploration of the bladder.

Chapter II Menstkuation"

Normal Menstruation. — The periodic flow from the mucous membrane of the body of the uterus, called the menses, usually makes its appearance when the girl is from thirteen to fifteen years old. The flow recurs every twenty-eight days, and ordinarily continues from three to five days. When the flow lasts less than three days it is usually scanty in quantity, and when it continues more than five days there is generally some pathological condition to account for it.

The flow commonly begins and ends with a flow of mucus without blood. The larger part of the menstrual discharge, as it escapes from the mucous membrane of the uterus, is a mixture of blood and mucus; but in addition there are some small round cells that have escaped through the surface and glandular epithelium and some epithelial cells. When the blood and mucus are present in the normal proportion, the discharge will not coagulate; but when there is an excessive proportion of blood, coagulation takes place. It is difficult to determine the quantity of blood lost at each period, but it is estimated that the average amount is about four ounces.

As the time of the flow approaches, the breasts become fuller and slightly tender, there is more or less feeling of general malaise, there is a sense of weight and heaviness in the pelvis due to congestion ; but under normal conditions there is no pelvic pain of any moment.

During menstruation there is no material loss of any

12 MENSTKUATION

portion of the endometrium. The blood escapes between the epithelial cells, and it is only over small areas that these epithelial cells are carried away.

The exact relation of ovulation to menstruation is not known. The changes in the endometrium during the menstrual cycle are described in the section on the anatomy of the uterus. These changes in the endometrium and the menstrual flow are in all probability due to an ovarian secretion.

Precocious Menstruation. — When regular menstruation begins at an unusually early age, it is known as precocious menstruation. This term does not include occasional bloody discharges that are usually due to some local lesion, nor the slight flow from infants that is sometimes observed soon after birth. In cases of precocious menstruation there is a premature development of the generative organs.

Delayed Menstruation. — When regular menstruation is not established until long after the usual age, it is called delayed menstruation. In these cases there is usually a failure of development of the genital organs or the delay may be due to anemia.

Vicarious Menstruation. — A periodic flow of blood from some other mucous membrane than that of the uterus is known as vicarious menstruation. It is rarely seen, but when it does occur the hemorrhage comes most frequently from the nasal mucous membrane.

MENOPAUSE

The end of the child-bearing period of a woman's life is known as the menopause, climacteric, or change of life. The most important phenomenon of this period is the cessation of ovulation ; but the most obvious indication that the individual has reached the menopause is the disappearance of

MENOPAUSE 13

the menses. In exceptional cases ovulation may continue after the menses have failed to appear, but ordinarily both cease at about the same time. The menstrual life of most women covers a period of a little more than thirty years. In a very large per cent of cases the flow ceases to recur about the age of forty-seven, but the age of cessation is subject to wide variations. The menopause may be established at the thirtieth or the flow may continue up to the fifty-seventh year. As the menopause approaches, the flow usually decreases in quantity for a few periods, skips an occasional period and then ceases. During the period of diminution and for a time after the final cessation of the menses, many women have flushes of heat and other nervous phenomena; but the establishment of the menopause is a physiological process, and many grave errors in diagnosis are made by charging up to " change of life " too many symptoms of which women of forty-five complain. It is of especial importance to remember that any excessive flow from the uterus, bloody or otherwise, about the time of the menopause is a danger signal that calls for immediate investigation. Over fifty per cent of women who begin to bleed from the uterus after the establishment of the menopause have some form of carcinoma of the uterus.

With the establishment of the menopause there is an associated atrophic process in the genital organs. The ovaries become small and cirrhotic. The Fallopian tubes decrease in size and the folds in the mucous membrane partially disappear. The uterus decreases in size; the atrophy of the cervix may go so far that only a little dimple is felt in the walls of the vagina. The vagina decreases in calibre, becoming more tubular or even funnelshaped. The folds in the vaginal mucous membrane disappear. The labia lose their deposits of fat and become little more than folds of skin.

l-± MENSTRUATION

DISORDERS OF MENSTRUATION

The disorders of menstruation are discussed briefly to impress upon the student that they are only symptoms of underlying pathological conditions, and that before any treatment is instituted the cause of the disorder must be discovered.

Amenorrhea. — Amenorrhea is the absence of the menses during that period of life when a woman should be menstruating regularly. A peimary amenorrhea is one in which the menses have never become established. A secondary amenorrhea is one in which the menses have ceased after they have become established. Primary amenorrhea is due to a failure of development of some of the reproductive organs. Secondary amenorrhea is frequently due to the anemia of chlorosis, tuberculosis, or some other disease that decreases the quantity of red blood cells. Destruction of the ovaries by disease or their removal by operation causes a cessation of menses. Among the more remote causes are change of climate and mental strain. Some very obese women cease to menstruate at a very early age, but the direct relation between the accumulation of fat and the amenorrhea has not been established. Recent observations indicate that in these cases of obesity there is a deficient secretion of the pituitary gland. There is a considerable number of cases in which the cause of cessation is not obvious. In primary amenorrhea, as a rule, the menses never appear; but in some cases the patient will menstruate for a few times, usually scantily and at irregular periods, and then the menses will cease. In secondary amenorrhea there is usually a progressive decrease in the quantity of flow for several periods before complete cessation. When a woman who is apparently in good