CORNELL UNIVERSITY THE Jlnmer ^et^rinarg Hibrarg FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. State Veterinary College 1897 Digitized by Microsoft® CORNELL UNIVEHSITY LIBRARY 3 1924 104 224 583 Digitized by Microsoft® This book was digitized by Microsoft Corporation in cooperation witli Cornell University Libraries, 2007. You may use and print this copy in limited quantity for your personal purposes, but may not distribute or provide access to it (or modified or partial versions of it) for revenue-generating or other commercial purposes. Digitized by Microsoft® Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924104224583 Diaitiz^ by Microsoft® Digitized by Microsoft® GYNECOLOGY By WILLIAM P. GRAVES, A. B., M. D., F. A. C. S. Professor of Gynecology at Harvard Medical School; Surgeon-in-Chief to the Free Hospital for Women, Brookline; Consulting Physician to the Boston Lying-in Hospital With 303 Half-Tone and Pen Drawings by The Author And 122 Microscopic Drawings by Margaret Concree and Ruth Huestis With 66 of the Illustrations in Colors PHILADELPHIA AND LONDON W.B.SAUNDERS COMPANY 1917 Digitized by Microsoft® Copyright, 1916, by W. B. Saunders Company Gl7 Reprinted February, igi? PRINTED IN AMERICA PRESS OF W. B 8AUNDER8 COMPANY PHILADELPHIA Digitized by Microsoft® TO THE MEMORY OF Dr. MiUiam M. Ba^er TEACHER AND FRIEND THIS BOOK IS GRATEFULLY AND AFFECTIONATELY DEDICATED :^:.'; N ^^r Digitized by Microsoft® Digitized by Microsoft® PREFACE This work is designed both as a text-book and general reference book of Gynecology. In order to meet these two requirements a special classification' has been adopted dividing the subject matter into three distinct parts: Part I deals with the physiology of the pelvic organs and with the relation- ship of gynecology to the general organism. The latter subject is a compara- tively new departure, and is presented in conformity with the latest methods of medical teaching which strive to impress on the student's mind the importance of the correlation of all branches of medicine and surgery. It is hoped that this part of the work will prove of value both to the advanced special student and to the general practitioner who includes gynecologic patients in his clientele. Part II is designed primarily for the undergraduate student who is taking his initial course in gynecology. It includes a description of those diseases which are essentially gynecologic, and is thus isolated in a somewhat compact form in order that the student may not be confronted by a too formidable array of facts in his collateral reading and in his preparation for his final examination in the subject. In order to accomplish this purpose certain encumbering details have been subordinated. Thus, in the description of each disease, the underlying pathologic processes are enumerated. Microscopic detail, however, can better be learned from pictures than from tedious descriptions. For that reason draw- ings from microscopic sections illustrating the respective diseases are presented under each subject with full descriptive legends appended to them. In like manner the surgical principles involved in the treatment of the various dis- eases are recounted, but the technic of the operations and the pictures illustrating their performance, matters of secondary interest to the student of the theory of gynecology, are reserved for a separate section. Part III is devoted exclusively to the technic of gynecologic surgery and is written for the assistance of the advanced student and practitioner. Surgical devices for the cure of gynecologic diseases are innumerable, and it is impossible to include them all in a book of this scope. Only those operations which from the personal experience or judgment of the author seem best suited for the special requirements are presented. Many excellent procedures have, there- fore, been unavoidably omitted. In preparing a work of this kind material must be gathered not only from the author's personal experience, but to a still greater extent from the work of others. Out of a great number of authorities consulted there have been several to which I have had such frequent recourse, both for new material and for cor- 9 Digitized by Microsoft® 10 PREFACE roboration of personal observations, that I must make a general acknowledg- ment of indebtedness to them. In writing the sections on the relationship of gynecology to the general organism I have received the greatest assistance from the monumental work entitled "Die Erkrankungen des Weibhchen Genitales in Beziehung sur inneren Medecin," published by Prof. Frankl-Hochwart as a supplement to Nothnagel's "Pathologie und Therapie." In writing Part II the authorities to which I owe most are the great "Handbuch" of Veit, the "Handbuch" of Opitz and Menge, the "Lehrbuch" of Kiistner, and the various works of Dr. Howard A. Kelly and his associates. In making the half-tone drawings I owe much to the instruction of Mr. Max Brodel, who many years ago showed me the technic which he has developed and which has been universally imitated, but never equalled, in the field of medi- cal illustration. To Miss H. J. Ewin, Superintendent of the Brookline Free Hospital for Women, I am indebted for the accumulation and tabulation of a vast number of statistics gathered from hospital records and patients' letters. On the basis of these statistics I have been able to draw many valuable conclu- sions. To my associate, Dr. F. A. Pemberton, belongs the credit of selecting the pathologic sections and of supervising the microscopic drawings, most of which have been executed by Miss Margaret Concree. The following illustrations have been previously published in an article by the author in the "American Practice of Surgery," Figs. 27, 28, 44, 50, 204-210, 214-216, 231, 238, 239, 245, 247, 248, 263, 264, 267, 268, 424. William P. Graves. Boston, Mass. Digitized by Microsoft® CONTENTS PART I— PHYSIOLOGY AND RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM PAGE Physiology of the Uterus and Ovaries 17 The Uterus 17 Physiologic Anatomy of the Ovary 31 Relationship of Gynecology to the General Organism 44 Relationship of Gynecology to the Organs of Internal Secretion 44 Ovary 44 Hypophysis 55 Thyroid 57 Parathyroids 61 Adrenals 61 Pineal Gland (Epiphysis) 63 Thymus 63 Uterus 63 Placenta 63 Relationship of Gynecology to the Mammary Glands 64 Relationship of Gynecology to the Skin 65 Relationship of Gynecology to the Organs of Sense 69 Relationship of Gynecology to the Digestive Tract 71 Relationship of Gynecology to the Organs of Respiration 74 Relationship of Gynecology to the Blood 76 Serodiagnosis 81 Relationship of Gynecology to the Organs of Circulation 83 Heart 84 Blood-vessels 86 Relationship of Gynecology to the Nervous System 91 Relationship of Gynecology to the Neighboring Organs 100 Relationship of Gynecology to the Gall-bladder 106 Relationship of Gynecology to the Peritoneum and Omentum 109 Relationship of Gynecology to the Bones and Joints 115 Relationship of Gynecology to Acute Infectious Diseases 116 Enteroptosis 117 Movable Kidney 126 Intestinal Bands - • • • 131 PART II— GYNECOLOGIC DISEASES Special Inflammatory Processes 136 Gonorrhea 136 Gonorrhea in Children ■ 138 Gonorrhea in the Adult • ■ 140 11 Digitized by Microsoft® 12 CONTENTS Special Inflammatory Processes — Gonorrhea — Gonorrhea in the Adult — page Urethritis 140 Inflammation of Skene's Glands 142 Inflammation of Barthohn's Glands 143 Endocervieitis 148 Endometritis 151 Salpingitis 151 Chronic Pelvic Inflammation as a Result of Gonorrheal Salpingitis 167 Serum and Vaccines in Gonorrhea 172 Genital Tuberculosis 173 Tubes 174 Uterus 177 Ovaries 178 Cervix 178 Vagina 178 Vulva 178 Peritoneum 179 General Inflammatory Processes 182 Inflammations of the Vulva 182 Soft Chancre 182 Skin Lesions 183 Esthiomene 187 Elephantiasis 188 Kraurosis 190 Pruritus 192 Vaginitis (or Colpitis) 194 Cervicitis and Endocervieitis 199 Endometritis 200 Infectious Endometritis 202 Chronic Interstitial Endometritis 205 Gland Hypertrophy 207 Metritis 209 Inflammations of the Ovary 210 Infectious Oophoritis 210 Interstitial Oophoritis 211 Parametritis and Pelvic Cellulitis 213 Inflammations of the Pelvic Cellular Tissue 214 Parametrial Hematoma 218 Urethritis 219 Cystitis 220 Tuberculosis of the Bladder 228 Syphilis of the Bladder 229 Cystitis Vetularum 229 Pyelitis 230 Inflammations of the Colon and Rectum 233 Diverticulitis 233 Ischiorectal Abscess 236 Fistula in Ano . 237 Fissure in Ano 238 Inflammatory Stricture of the Rectum 239 New Growths _ 242 Tumors of the Vulva 242 Fibroma, and Fibromyoma 942 Lipoma 24Q Digitized by Microsoft® CONTENTS 13 New Growths — Tumors of the Vulva — PA OB Carcinoma 243 Sarcoma 246 Varicocele _ _ 246 Urethral Caruncle 247 Urethral Prolapse 248 Tumors of the Clitoris 249 Tumors of the Vagina 250 Sarcoma 250 Carcinoma 251 Cysts 253 Tumors of the Uterus 257 Myoma 257 Adenomyoma 277 Sarcoma 278 Cervical Polyps 282 Cancer of the Cervix 284 Cancer of the Body of the Uterus 303 Chorio-epitheHoma Malignum 311 Tumors of the Ovaries 322 Follicle Cysts 322 Corpus Luteum Cysts 326 Parenchymatous Timiors 328 Cystadenoma 328 Carcinoma 339 Dermoid Cysts 342 Teratoma 345 Stromatogenous Tumors 348 Sarcoma 351 Symptoms 353 Diagnosis 356 Treatment 357 Prognosis 358 Parovarial Cysts 359 Tumors of the Tubes ; .- 361 Carcinoma 361 Other Tumors of the Tube 362 Tumors of the Round Ligament 363 Tumors of the Pelvic Connective Tissue 364 Tumors of the Bladder 367 Papilloma 367 Carcinoma 368 Vesical Calculus 369 Tumors of the Rectum 370 Cancer 370 Adenoma 372 Prolapse 372 Hemorrhoids 373 Defects op Development 377 Congenital Defects of the Uterus 382 Vagina 385 Ovaries and Tubes 386 Urethra and Bladder 386 Atresia of the Anus 390 Pseudohermaphroditism 392 Digitized by Microsoft® 14 CONTENTS PAGE Malpositions of the Uterus 394 Retroversion and Retroflexion - 399 Retroversion due to Relaxation 400 Retroversion due to Adhesions ■ • ■ • 409 Retroversion due to Displacement by Tumors • . ■ 411 Prolapse and Procidentia • 411 Prolapse • 411 Procidentia • 416 Anteflexion • • • • 421 Inversion • 423 Injuries Due to Childbirth • • ■ 426 Lacerations of Cervix • 426 Cystocele 428 Lacerated Perineum 431 Vesical Fistula - 434 Abdominal Hernia 436 Umbilical Hernia 438 Postoperative Hernia 439 Special Gynecologic Diseases 442 Ectopic Pregnancy 442 Dysmenorrhea 451 Essential Dysmenorrhea 451 Membranous Dysmenorrhea 457 Amenorrhea of Youth 459 Menorrhagia of Youth 460 Vaginismus 461 Gynatresia 463 Genital Atrophy 468 Uterine Insufficiency 475 Inf antiHsm and Sterility 477 General Symptomatology in Gynecology 496 Symptoms due to Abnormal Secretions 496 Abnormalities of Menstruation 499 Amenorrhea . 499 Menorrhagia 501 Metrorrhagia 503 Pain 504 PART III— OPERATIVE GYNECOLOGY Operations on the Vulva 510 Vulvectomy 510 Operations on Bartholin's Glands 512 Operations on the Cervix 514 Dilatation of the Cervix 514 Curetage 515 Tracheoplasty 516 Amputation of the Cervix 522 Schroder's Operation 526 Operations on the Vagina 53O Anterior Colpoplasty (Author's Method) 530 Operation for Functional Incontinence of Urine 535 Digitized by Microsoft® CONTENTS 15 Operations on the Vagina — p^^j, Emmet's Perineoplasty (Author's Technic) 538 Enlarging a Tight Perineum 546 Operations for Complete Laceration of the Perineum 547 Operations for Vesical Fistulae 553 Operations for Atresia of the Vagina 565 Operations for Absence of Vagina 567 Schubert's 570 Baldwin's 570 Vaginal Celiotomy 575 Anterior and Posterior Colpotomy 575 Operations fob Uterine Malposition 578 Operations for Retroversion 578 Olshausen's Operation for Suspension of the Uterus (Author's Technic) 578 Various Forms of the Gilliam Operation 580 Simpson's Operation 581 Mayo's Modification of GiUiam's Operation (Internal Alexander) 583 Kelly's Modification of Gilliam's Operation 585 Baldy's Operation (also called the Baldy- Webster Operation) 585 Alexander's Operation 588 Operations for Anteflexion 591 Pessaries for Anteflexion of the Cervix 591 Operations on the Cervix for Anteflexion 593 Abdominal Operation for Anteflexion (Author's Method) 595 Operations for Prolapse and Procidentia. 596 Procidentia 596 Watkins' Interposition Operation 599 Goff e's Operation , 606 Mayo's Operation 609 Conservative Operation for Inversion of the Uterus 610 Spinelh's Operation for Inversion of the Uterus 611 Hysterbctomt Operations 613 Supravaginal Hysterectomy 613 Complete Hysterectomy 624 Vaginal Hysterectomy 628 Wertheim's Extended Operation for Cancer of the Uterus 631 Extended Vaginal Hysterectomy for Cancer of the Cervix 644 Myomectomy Operations 650 Abdominal Myomectomy 650 Vaginal Myomectomy 653 Operations on the Tubes 656 Salpingp-oophorectom.y 656 Salpingectomy 657 Salpingostomy (Stomatoplastic) 659 Operation for Tubal Sterilization 661 Operations on the Ovaries 662 Resection of the Ovary 662 Transplantation of Ovarian Tissue 663 Operations on the Abdominal "Wall 666 Bardenheuer's Incision 666 The Pf annenstiel Incision 667 Digitized by Microsoft® 16 CONTENTS Operations on the Abdominal Wall — page Operation for Diastasis of the Rectus Muscles 669 Operation for Umbilical Hernia (Author's Method) 673 Mayo's Operation for Umbilical Hernia 679 Operation for Postoperative Hernia 680 Transplantation of Fascia for Postoperative Hernia 680 Operations on the Kidney 684 Minor Operations 684. Suspension of the Kidney (Kelly's Technic) 688 Incision for Major Operations on the Kidney 691 Nephrectomy 691 Operations on the Ureters 698 Uretero-ureterostomy 698 Ureterocystanastomosis 700 Extirpation of the Kidney 701 Ligation of the Proximal End of the Ureter 701 Formation of Ureteral Fistula 702 Operations on the Bladder 703 Suprapubic Cystotomy 703 Vaginal Cystostomy 703 Operations on the Rectum 705 Operations for Prolapse 705 Operations for Hemorrhoids 707 Operations for Fistula in Ano 712 Elting's Operation for Fistula in Ano 715 Operations for Varicose Veins of the Leg .'.... 716 Technic 719 Examination of the Patient 719 Pelvic Examination in a Private House 722 Abdominal Operations 723 Technical Detail in Conduct of Abdominal Pelvic Operations 724 Postoperative Treatment of Abdominal Cases 728 Technic of Plastic Surgery 730 Technical Details 731 After-care 733 Index 737 Digitized by Microsoft® GYNECOLOGY PART I PHYSIOLOGY AND RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM Physiology of the uterus and ovaries the uterus During the first decade of life the female genitalia play a very unimportant physiologic role/ In the last months of intra-uterine life there is a somewhat rapid development of the uterus, and at birth is often seen a discharge which appears Kke true menstrual blood. The uterus then for several months under- goes a process of regression, from which period there is a very slow growth until the time of puberty. The hypertrophic changes in the uterus just before and after birth are at present supposed to be due to the action of hormones from the placenta, which influence the development of the maternal uterus and that of the child, both of which undergo involution when the stimulus of the placenta is removed (Halban). At birth the uterus is high in the pelvis and pressed backward by the intes- tines which lie in the utero vesical space. At this time it is pointing upward and its axis is practically straight. During the first ten years of life it sinks gradually deeper in the pelvis, and acquires the angulation between body and cervix known as anteflexion. There is also a tendency to sag backward toward the sacrum into the position of retrocession. The persistence of this position after maturity constitutes the typical condition of local infantilism. The growth of the inner genitaha during the first ten years is comparatively slight, but toward the age of puberty there is a very marked and rapid develop- ment. The uterus does not usually attain its full growth in the virgin until several years after puberty. Child-bearing increases the size and weight of the uterus, so that it measures on an average 1 cm. more in each dimension than does the virgin uterus and weighs about 20 gm. more. The length of the virgin uterus is 7 to 8 cm., and its weight from 40 to 50 gm. During lactation the uterus undergoes a tempo- 2 1" Digitized by Microsoft® 18 GYNECOLOGY rary atrophy due to a shrinking, but not a loss of the muscle-fibers, and normally regains its proper size after lactation ceases. At the menopause the uterus becomes permanently atrophied as a result of a diminution both in size and amount of muscle tissue. The ovaries of the child during the first ten years also show an insignificant growth. The infantile ovary is narrow and slender. Toward puberty there is a rapid development, and the organ assumes a rounder, more oval contour. The dimensions of the mature ovary are 3 to 5 cm. long, 2 to 3 cm. wide, and 1 to I5 cm. thick. In the fetus the tube is twisted into tight convolutions, which straighten out somewhat toward the end of intra-uterine life, especially near the isthmus. As the child grows older the tube gradually becomes straighter, so that at puberty there are only moderate convolutions. After child-bearing the tube becomes nearly straight. The twisting of the tube sometimes persists after maturity, and is regarded as one of the stigmata of infantilism. It is thought to be one of the causes of sterility and of tubal pregnancy. At puberty the secondary sexual characteristics become more pronounced and differentiated from those of the male. Most important of these are the development of the breasts, relative width of the hips, slenderness of the waist, length of the hair of the head, small bony structure, general undulating contour of the body, and absence of body hair, except in the axillae and on the pubes. The breasts at the time of birth, both in boys and girls, are enlarged, and, like the female uterus, undergo retrogression in the first few weeks. It is thought that this enlargement of the breasts at birth is due to the influence of the placenta, to which is also ascribed the growth of the maternal breasts during pregnancy. The rapid mammary development at puberty and the temporary enlargement during menstruation is probably referable to the in- fluence of the ovarian inner secretion (Halban-Schroder) . Woman reaches her highest period of development and her greatest fertility about the middle of the third decade of life. Physiology of Menstruation.— Menstruation is probably estabUshed at the time of the first complete ripening of an ovum. The first appearance of blood usually takes place at about the fourteenth year, though in some it begins as early as eleven and in others as late as sixteen. These may be regarded as the normal limits. Precocious menstruation in infants is usually due to some disturbance in the glands of internal secretion, while late menstruation (i. e., after sixteen) is commonly the result of some ovarian deficiency, either primary in the ovaries themselves or secondary to the influence of other glands of in- ternal secretion. There are, however, numerous factors which influence the estabUshment of the menses; one of these is climate. Climate apparently affects the period of puberty somewhat, but not to the extent formerly supposed. It is commonly stated that in tropical regions menstruation begins usually from eight to nine Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 19 while in the colder regions it is much later than the general average. Engleman has, however, shown in extensive statistics that this is an error, and that the average age of puberty is very nearly the same in the tropics and in the arctic zones — namely, about fourteen and one-half years. In the Polar regions women are said to menstruate from two to four times a year, as a rule, and not at all during the winter months. Heredity plays a certain role, as do general racial characteristics, but the variations from these causes are not wide. Social conditions also make some difference, for statistics show that the poor begin to menstruate later on an average than the well-to-do and reach the menopause earlier. This is thought to be due to hard work and poor nourishment. It has also been observed that those who live in the country come to puberty later than those who live in the city, probably for the same general reasons. It must be remembered that these figures have been compiled from European countries, where social conditions differ from those in this country. Statistics on this subject in America are scanty. The duration of menstrual life is usually between thirty and thirty-five years. Kniger's table is as follows : Menopause at 36^0 12 per cent. Menopause at 41-45 26 " " Menopause at 46-50 41 " " Menopause at 51-55 15 Menopause before 35 and after 55 7 " As a rule, those in whom puberty comes early have the menopause some- what later than the normal. Women of this type tend to menstruate more profusely and have a special predisposition to myoma formation, which of itself prolongs menstrual life. NulHparous women and virgins reach the climacteric somewhat sooner than do parous women. Women of the upper classes menstruate distinctly later than women of the poorer classes, the menopause of the former averaging nearer fifty than forty- five. Undoubtedly better nourishment and freedom from hard work explain this fact. It is usually stated that the menopause appears eariier in hot climates than it does in cold. Statistics on this point are conflicting. It is probable that climate has no very decided influence on the menopause, but that in those countries where it appears abnormally, early it is affected chiefly by the very early child-bearing to which the women are subjected and by which they pre- maturely lose their bloom. When the function of menstruation is estabhshed it is apt to be irregular at first, but when fully instituted the typical intermenstrual period is from twenty-seven to thirty-one days. There seems to be a special type of women who menstruate every twenty-three days. This type is usually of the class who begin eariy and have a late climacteric. It is probable that in most women Digitized by Microsoft® 20 GYNECOLOGY who menstruate every twenty-one to twenty-three days there is some under- lying pathologic condition. In healthy women the average length of the menses is three to four days. These limits may fluctuate somewhat and still be regarded as normal. In general, however, women who menstruate only one or two days, and those who flow more than five days are not to be regarded as entirely within physiologic hmits. The amount of blood lost at each menstruation has been variously estimated by different investigators. It probably averages about 50 gm. in the unmar- ried and somewhat more in the married and parous (Hoppe-Seilet). Menstrual blood is more watery and paler than normal blood, and is mixed with detritus and the secretions of the uterus, cervix, and vagina. The most important characteristic of the menstrual blood is its non-coagula- bility. This was formerly supposed to be due to the influence of the alkaline cervical mucus, on the ground that blood when alkaline is less coagulable than when acid. The cervical mucus, however, is probably not account- able for the phenomenon. Birnbaum and Osten have shown that the body blood of a menstruating woman is only one-half as coagulable as it is when she is not menstruating, but this has recently been denied. The change was thought to be due to some agent which affects the entire organism of the woman, and was referred to the influence of the ovarian secretion. It is now supposed to be due to a local influence of the ovarian secretion exerted on the endometrium. During menstruation there is marked congestion of all the pelvic blood- vessels, and as a result the uterus is larger and softer and more compressible. The tubes and ovaries are also swollen. The external genitals exhibit a decided hyperemia. The breasts are somewhat fuller and often tender and painful, and in some there is a noticeable enlargement of the thyroid gland. A few women experience a special sense of well-being during the menstrual period, but in most women there is a general physical and mental depression which is manifested in many different ways. The nervous equilibrium especi- ally is unstable. There is increased irritabihty and susceptibility to psychic excitement. All neurotic tendencies are accentuated and often appear at this time only. Headaches periodically associated with some particular time of the menstrual period are very common. (See also section on Neurology.) The majority of women have some form of pelvic discomfort during cata- menia. Under physiologic conditions this may be merely a sense of heavi- ness or pelvic pressure. If there is actual pain, the condition is one of dys- menorrhea (g. v.). The symptoms of any pathologic process, especially of the lower abdomen, like appendicitis or salpingitis, are exaggerated by the menstrual congestion. Practically, all of the functions of the body may share in the general depres- sion and exhibit symptoms more or less disturbing. In the digestive system Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 21 there may be loss of appetite, tendency to vomiting and formation of gas in the intestines, increased mucus from the colon, and constipation or diarrhea. The circulatory system may show irregular pulse and palpitation of the heart. Various vasomotor disturbances are frequent, such as hot flushes, cold ex- tremities, sweating, etc. The mucous membrane of the nose and throat is often swollen, causing mouth-breathing. Nose-bleeds are frequent. The vocal chords become swollen, so that there is a change in the voice. Singers experience a change in the quality and trueness of their notes, and often are obliged to refrain from singing in public during the menstrual period. The hearing is apt to be less acute, while the eyes, too, may suffer from granulation of the lids, lessening of the field of vision, and impairment of color sense. Various skin manifestations are common during the menstrual period, examples of which are exanthematous rashes, herpes of the lips, urticaria, acne, etc. The sexual impulse is, as a rule, increased just before and just after the catamenial flow. It is usually decreased during the period, but may be in- creased. Some patients suffer pain and discomfort about half-way between their periods, resembling that which they have at their regular flow. This intermenstrual pain is usually due to some pathologic process, most com- monly an intramural fibroid. In other cases it cannot be explained by any anatomic lesion. Precocious menstruation relates to the appearance of the menses in infants of two to four years old, associated with abnormal development of the breasts and external genitals, growth of pubic hair, and awakening of the sexual im- pulse, usually shown by masturbation. This condition is the result of abnor- malities in the glands of internal secretion, and is referred to in detail in the section on the Internal Secretory Organs. Vicarious menstruation is a phenomenon about which httle is known but which undoubtedly occurs at times. Instead of the regular menstrual flow, bleeding takes place more or less periodicafly from some other organ of the body, usually the nose. Other sites of vicarious bleeding described are the hps, breasts, lungs, rectum, hemorrhoids, ulcerations, and wounds, vicarious menstruation from the nose is sometimes seen after hysterectomy operations, where an ovary has been left in situ or where a piece of it has been transplanted. The menses may be influenced to some extent by psychic excitement, especi- ally that due to fright or anxiety. In women who menstruate normally the flow after having started may be suppressed by a sudden nervous shock, or such a shock may bring on the menses out of the regular time. It is a com- mon experience in a gynecologic clinic that women whose periods are usually regular menstruate out of time under the mental excitement of waiting for operation. Menstruation is often delayed for several days and even a week in women who are laboring under the fear of impregnation, and also in women who, being extremely anxious to become pregnant, have their minds tensely concentrated on the function. Digitized by Microsoft® 22 GYNECOLOGY The question of performing pelvic operations during the menstrual period is one of some importance and one concerning which there is difference of opinion. Some operators make it a rule never to operate at this time, while others pay little attention to the matter. It is probable that in the majority of instances patients operated on during the catamenia have a normal con- valescence, but occasionally it happens that a constitutional effect is pro- duced by the operation that results in alarming syxaptoms. These appear within thirty-six or forty-eight hours after the operation and simulate closely the condition of profound shock. Patients in this state have had their abdomens reopened in the belief that they were suffering from a secondary internal hem- orrhage. The condition lasts for several hours and then passes away. No entirely satisfactory explanation has been made of this phenomenon. The effects of menstruation on the general organism mentioned above are treated in greater detail in other sections. The Climacteric. — The menopause is usually a slow change extending over several months to several years. Menstruation in rare instances ceases abruptly; more commonly there is a gradual cessation, consisting either of a progressive diminution in the amount of flow or in a lengthening of the intermenstrual period. Many women before the end of the menopause exhibit a greater pro- fuseness in the flow and shorter intermenstrual periods. An increase of blood during the menopause is not to be regarded as physiologic, a misconception which often leads to grave errors. The most common pathologic causes of menorrhagia at the menopause are cancer, fibroids, and polyps. In manj' cases, however, no definite anatomic changes can be discovered, and the bleed- ing must be referred to an insufficiency of contractile power on the part of the uterine musculature. This uterine insufficiency is not normal or physiologic, for it subjects the patient to a period of semi-invalidism which may last over several years. When the menopause is estabfished all the genital organs undergo a process of atrophy, which in extent varies greatly in different women. (For a detailed description of Genital Atrophy, see page 468.) Many women pass through the menopause with Httle or no trouble and this may be considered the norm. There are, however, certain constitutional and psychic disturbances of a quasiphysiologic nature which perhaps the major- ity of women experience to a greater or less extent. These may occur only at the time of the actual menopause, but they may make their appearance several years before any change takes place in the function of menstruation and may last long after it has ceased. The most typical of these disturbances are hot flushes, palpitation, buzzing in the ears, dizzy feelings, nervous irritability, tendency to depression, various forms of neuroses, and often serious psychoses. It is a common belief also that certain physical changes take place, such as a deepening of the voice, appear- ance of hair on the upper lip and chin, accumulation of fat, and a general coarsen- Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 23 ing of feature and contour. This last so-called reversion to the masculine type has been greatly exaggerated. Women who have a tendency to obesity begin to grow fat long before the menopause, as a rule, while those who eventually develop coarseness of feature show this characteristic as soon as the bloom of youth begins to pass. The appearance of hair on the face in middle age is not a universal attribute, but only an individual peculiarity, and is merely evidence of advancing age. Women of innate physical refinement often show a greater delicacy of lineaments as they approach and pass the climacteric. The vasomotor and psychic disturbances referred to above are thought to be the result of the loss of ovarian secretion. Doubtless the atrophy of the ovaries does account for some of these manifestations, especially those of the vasomotor type, but this influence has also been greatly exaggerated. Severe manifestations of this kind nearly always appear in individuals with well- marked neurotic predisposition, while women of the well-balanced type usually suffer little. As Walthard has pointed out, the so-called critical period of a woman's life comes at a time when domestic responsibilities and worries are at their height, while the consciousness of approaching old age and the loss of physical attractiveness constitutes a most important factor in the discon- tent and mental despondency that women of middle age, especially of the social classes, are wont to exhibit. Just before the climacteric there is usually an increase of the sexual impulse. This may last for a considerable time, but, as a rule, it gradually diminishes. After the age of fifty or thereabouts women often undergo a complete change in temperament. Reheved of the anxieties of child-raising, and reconciled to the changes of age, they acquire a mental and physical strength never before experienced, and hve for a decade or two the best years of their life. Physiology of Conception. — During coitus there takes place a hypersecre- tion of the glands of the vestibule and of Bartholin's glands, the evident pur- pose of which is for lubricating the parts. The semen is deposited in the poste- rior vault of the vagina, which is termed the receptaculum seminis, into which under normal conditions the cervix dips. It was formerly supposed that the semen was received directly into the cervical canal, but this cannot be so, as the cervix normally points at right angles to the axis of the vagina. Another proof that the semen does not enter directly into the cervix is the fact that in retroversion or anteflexion, where the cervix points in the direction of the canal, and in a more favorable position for receiving the semen, conception usually does not take place. From the receptaculum seminis the spermatozoon reaches the cervical canal chiefly by its own power of locomotion, but it is undoubtedly assisted by the cervix and its mucous secretion. During orgasm the cervical glands pour forth strings of mucus from their ducts, which, dipping into the pool of semen, act as channels for the passage of the spermatozoa into the canal. It has been claimed that -the cervix during orgasm undergoes certain muscular movements Digitized by Microsoft® 24 GYNECOLOGY which serve to aspirate the semen into the lumen. The normal alkaline reac- tion of the cervical mucus undoubtedly also plays an important part in the process, for spermatozoa soon die in the acid medium of the vaginal secretions. The chief factor for motion in the upward progress of the spermatozoon is un- questionably its own motility. As proof of this is the occasional conception that takes place where the cervix has been amputated, in which there is little question of cervical secretion or aspirating movements. That the spermato- zoon is capable of weathering a journey through acid secretions the length of the vagina is shown by the not infrequent cases of conception where there has been no introition. It is now well accepted that the unioh of the spermatozoon and ovum takes place either at the fimbriated end of the tube or on the surface of the ovary. The union of the two germ-cells (amphimixis) is consummated by the success of one spermatozoon in piercing the surrounding envelope of the egg. Only the head which contains the nucleus of the male germ-cell enters the ovum, the tail breaking off. On the entrance of the spermatozoon the envelope of the ovum immediately becomes thickened, preventing penetration by other aspirants. The impregnated ovum is then guided by the fimbriae of the tube to the canal where it is swept on to the uterus, partly by the current of the cilia of the surface epithelium and partly by peristaltic motions of the tubal wall. The passage of the ovum to the uterine canal occupies several days to possibly a week. During this time it acquires the power of corrosion, which is characteristic of fetal tissue, and when it reaches the uterine canal it digs a bed for itself in the endometrium where it proceeds to develop, nourished as a parasite by the mother's blood. If the passage into the uterine canal is in any way interrupted the egg sinks into the mucous membrane of the tube and produces an ectopic pregnancy. Orgasm on the part of the woman is not necessary to conception, although its absence is often associated with sterility, especially in cases of hypoplasia. That orgasm and libido are not essential factors in conception is proved by the frequency with which frigid women become mothers, and by the recorded instances of impregnation during narcosis. Physiologic Anatomy of the Menstruating Endometrium. — That the uterine mucosa passes through definite cyclic changes each month is a comparatively recent addition to our knowledge, due chiefly to the researches of Hitschmann and Adler, who rediscovered facts that had already been announced years before. The cycle of change is divided into three phases: (1) Premenstrual con- gestion, (2) period of menstruation, and (3) postmenstrual involution. The premenstrual congestion begins about ten days before the expected period. By this process there is a marked thickening of the mucosa, due to an hypertrophy and hyperplasia of the endometrial glands and a transudation and exudation into the stroma. The mucosa becomes two or three times thicker Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 25 Fig. 1. — Premenstrual Endometrium. Low power. At the bottom is the muscle of the uterine wall, sharply demarcated from the endometrium. The glands in the deepest part of the endometrium are small, their epithelial cells low, for this part of the gland remains inactive. The stroma cells are small and lie close together. At the middle of the endometrium the glands are dilated, the epithelium wavy, and the epithelial cells swollen and actively secreting mucus. The stroma cells are larger and lie further apart. On the right the dilatation of the blood-vessels is well shown. Near the top the glands have the same characteristic as at the middle, but there is more edema of the stroma. Throughout there is a slight infiltration with round cells. Digitized by Microsoft® 26 GYNECOLOGY than the normal, and may reach 6 to 7 mm. in depth. The surface becomes irregular and furrowed as a result of the general swelHng beneath. At this stage the endometrium resembles closely an early decidua vera. The stroma cells are large, pale and swollen, and separated by the edematous exudate. The mucosa is distinguished by two fairly well-defined layers, the deeper con- taining the dilated and hypertrophied glands, termed the spongy layer, and Fig. 2. — Pkbmenstbual Endometrium. • ^i'^^ ?°"5^'"'' '^^'^ drawing shows the enlargement of the nuclei of the epithelial cells, which, instead of being small and lying at the bottom as in inactive glands, have enlarged and nearly fill the cells. The cells crowd each other and a papilla can be seen in the central gland. the outer, denser, and less glandular portion, called the compact layer. The dilated blood-vessels (seen chiefly between the spongy and compact layers) are surcharged with blood. By diapedesis and by actual rupture (rhexis) blood is poured into the. stroma of the mucosa, and by following the Hne of least resistance toward the surface forms subepithelial hematomas. It is probable that at this point uterine contractions force the blood through the surface of the mucosa into the uterine canal, marking the second phase of the cycle, the Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 27 f ?|'-" r^s B'SHW ^a ^%f 5> (^ *« ZP ^'^^i L.^Sk£l:ii£Z£?SJ«>v«^ Fig. 3. — Pkemenstbual Endometbium. High power of part of a gland. This shows especially well how the epithelium of the glands is thrown out in tuft-like projections during this stage. The lower part of the gland is dilated, while the neck near the surface is narrow, holding the secretion in the gland. Digitized by Microsoft® 28 GYNECOLOGY menstrual flow. The blood escapes into the lumen, partly through the inter- stices between the epithelial cells and partly by actual rupture of the cell layers, small clumps of which may be desquamated and discharged mixed with the menstrual blood. ®> > -Va, '% jp^l ^®i 9&Q. ^^>^r/ \^^^''i '■;■« ;.^^?a ■ „ & '^ " »®%«v, ^^a,©" t'*.?!^^ TTu-r/, O.Hui^sTlS pi-C— — Fig. 4. — Peemensteual EwDOMETRitrM. High power. The glands are dilated and several show invaginations of epithelium, the begin- ning of one of which is seen in the lower left-hand corner. The epithelial cells are swollen, the nuclei large and nearly filling the cells. The stroma cells are swollen and lie far apart, due to edema. A dilated blood-vessel is seen in the upper right corner. A few round cells are scattered through the tissue. With the cessation of the bleeding begins a regeneration of the mucosa. The secretion becomes clearer and finally disappears. The mucosa returns to its previous thickness of 2 or 3 mm. The blood-vessels shrink to their normal size, and the extravasated blood in the stroma gradually becomes absorbed, leaving for a time small brownish pigmented spots. The broken surface epi- Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 29 thelial layer becomes regenerated by the growth of new cells. The hyper- trophied glands, which during the premenstrual stage became lengthened, spiral-shaped, and distended with secretion, discharge their contents during the period of menstrual flow and then resume their original small narrow form Fig. 5. — Menstruating Endomethium. Low power. At the top the surface epithehum is gone on the left. The glands throughout / have discharged their contents and collapsed. The epithelial cells are still swollen. The stroma is very edematous and infiltrated with blood, especially on the left. At the bottom the glands are still somewhat dilated, but there is very little edema of the stroma. and straight direction. When the bleeding has ceased, the edema of the stroma disappears and the pale swollen stroma cells regain their former appearance. The postmenstrual regenerative stage lasts about fourteen days, when the rhythmical changes in the mucosa begin anew. If no menstruation takes place, or, in other words, if conception has Digitized by Microsoft® 30 GYNECOLOGY occurred, the premenstrual mucosa maintains its character and merges into a true decidua. It has been shown that during the cyclical change there is an increasing glycogen production from the mucosa, which reaches its height during the menstrual flow, after which it disappears, until the premenstrual stage begins again. This glycogen production is undoubtedly a provision for the nourish- ment of the egg. During the period of flow the superficial epithelial cells of the mucosa are said to lose their cilia. These are restored during the postmenstrual regenera- tive stage. Fig. 6. — Endometrium At Beginning of Menstruation. The glands, except for the one seen in the center, have collapsed, having discharged the mate- rial which was secreted during the premenstrual stage. The blood-vessels have been eroded by the ferment contained in the secretion, allowing the blood to exude into the tissue and on the sur- face of the endometrium. The surface epithelium in this section is still intact. The cervical mucous membrane takes no part in the menstrual bleeding, but secretes an increased amount of mucus. There is a question as to whether the tubal mucous membrane shares in the bleeding. It probably does not, as a rule, but there is evidence from abdominal operations done during the men- strual period, where the tube can be inspected, that there is sometimes an associated tubal menstruation. The researches of Hitschmann and Adler have been questioned to some extent, but in the main they are now nearly universally accepted. Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 31 Fig. 7. — Postmenstrual Endometrium. Low power. The surface epithelium is regenerated. The glands are still dilated, but the epi- thelium is low, the nuclei of the cells small and lying at the bases. There is some edema of the stroma near the top, but the cells are smaller, the blood-vessels collapsed. There is a slight infiltration with round cells and blood-corpuscles. PHYSIOLOGIC ANATOMY OF THE OVARYi In our present knowledge of gynecologic physiology the ovary has assumed such a commanding position that it is necessary to devote special attention to its functional anatomy. The ovary is covered by a single layer of low cuboidal cells, called the ger- minal epithelium, which unites with the peritoneal endothelium in an irregular line at the hilum. This germinal epithelium is embryologically continuous with the epithelium of the tubal and uterine mucosa. Though modified and appar- ently insignificant in its role as a covering of the ovary, it nevertheless has extraordinary potentiahties for growth, and is probably the chief factor in the etiology of parenchymatous ovarian cysts. During childhood the surface of the ovary is for the most part smooth, but ' Chief authority, Schroder in Opitz and Menge. Digitized by Microsoft® 32 GYNECOLOGY after puberty the scarring process of ovulation gives it an irregular furrowed appearance. Under the germinal epithelium is a thin, rather dense layer of fibrous tissue, which gives the ovary its whitish appearance and which is called the albuginea. This structure is not fully developed until the time of puberty, and at that time consists of three layers of connective tissue. In old age and certain pathologic conditions it becomes much thickened, and if abnormally thick may play a part in the causation of sterility. Beneath the albuginea is the parenchymatous layer, which consists of a characteristic cellular connective tissue in which are contained the follicles. Merging into the parenchymatous layer is the medullary layer at the hilum, through which pass the blood- and lymph-vessels, nerves and connective tissue, ToWX Fig. S. — Formation of Follicles, from the Ovary of a Newborn Infant. Germ-cells can be seen in the outer germinal layer of epithelium. The germinal epithelium can be_seen growing inward and eventually surrounding the germ-cells by a single layer of cells. (After Kiistner.) and muscle-fibers from the broad ligament. In this layer are found small glandular ducts, which are by some thought to be the remains 'of the Wolffian ducts and are supposed to connect with the parovarium. A more recent theory is that they are off-shoots from the germinal epithelium. The follicles are confined exclusively to the parenchymatous layer. It is estimated that at birth the individual is endowed with about 30,000 of these follicles, and it is generally accepted at the present time that no new ones are created after birth. The essential function of the ovary consists in the development and ripening of the follicles. This process begins very early, probably at the end of intra-uterine life. Up to the age of puberty the ripening follicles become atretic or aborted, and only at that time do they begin to develop into true corpora lutea. From puberty there is a continuous process Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 33 of development of the follicles until the menopause, when they disappear entirely. In the maturing process there are three stages to be distinguished: (1) the primordial follicle, (2) the ripening follicle, and (3) the ripe Graafian follicle. (1) The primordial follicle hes embedded in the stroma of the ovary, imme- diately under the albuginea. It consists of the naked egg surrounded by a single layer of low flat epithelium. The primordial egg is an ellipsoid, mem- braneless cell fairly constant in size. The cell-body is composed of a clear protoplasm in which can be distinguished a very fine network. In the center Fig. 9. — Primordial Follicles from the Ovary of a Woman of Twenty-five. The central protoplasmic mass is the germ-cell or egg. It is enveloped by a single layer of epithelium. (After Veit.) of the body is a round nucleus with a definite surrounding membrane. The nucleus contains an eccentrically lying nucleolus, which is not always observable in the fetus and newborn, its absence showing probably an immature stage of development. The epithehal layer of the folhcle has been shown to be derived from the germinal epithehum which surrounds the ovary, and, as will be seen, is a structure of much importance. The fundamental function of the ovary represents a repeated ripening of the primordial follicles. They can be seen in lessening numbers up to the time when ovulation ceases at the menopause. (2) The Ripening Follicle.— When the folhcle begins to ripen the surround- ing epithehal cells begin to multiply by mitosis and to heap up into several 3 Digitized by Microsoft® 34 GYNECOLOGY layers. The cells now assume a larger and more cuboidal form and lie closely around the egg. Soon in this mass of cells there appears a vacuolization, or clear space, which becomes filled with fluid, the so-called liquor foUiculi. The clear place containing the liquid is crescentic in form, partly encompassing the egg. Several layers of epithelial cells continue to envelop the egg, and the mass thus formed juts out into the liquor like a peninsula. The collection of protecting cells that surround the egg is called the discus proligenis (or cumulus oophorus), while the rest of the epithelium around the periphery of the follicle is called the membrana granulosa. Fig. 10. — Graafian Follicle. High power. Three follicles are seen which are in the earliest stages. The center one has begun to show proliferation of the cells. These cells were originally derived from the germinal epi- thelium covering the ovary. No ova are seen. At the same time that these changes are going on inside the follicle, it is being surrounded on the outside by a concentric envelope of connective tissue, termed the theca folliculi. This envelope is plainly divided into two layers' that lying farthest away from the follicle being termed the tunica or theca ex- terna, and that lying next to the follicle being called the tunica or theca interna. The tunica externa is thick and dense and consists of circularly arranged connective-tissue fibers. It contains the blood- and lymph-vessels that supply Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 35 Fig. H. — Early Development of the Follicle. On the left are two primordial follicles, the upper showing the egg and surrounding follicle epi- thelium ; the lower showing the manner in which the follicle epithelium completely surrounds the egg. The middle picture shows the earliest stage of ripening in which the follicle epithelium multiplies into several layers. The third picture shows a further development of the follicle epithelium and the beginning of the cresoentic clear space containing the liquor foUiculi. (After Bumm.) ■^/isSj Fig. 12. — Graafian Follicle from the Ovary of a Newborn Infant. The clear space around the layer of epithelium is the result of an artefact in preparing the section. (After von Winckel.) Digitized by Microsoft® 36 GYNECOLOGY the follicle. The tunica interna is also composed of connective tissue, but is much more cellular than the externa. These cells are large and rich in proto- plasm and are epithelioid in character. Toward the end of the ripening stage they are actually larger than the epithelial cells of the membrana granulosa. Meanwhile the egg also undergoes a change. It becomes surrounded by a strong homogeneous capsule, the zojia pellucida. The protoplasm of the egg does not come in direct contact with the zona pellucida, there being between the two the so-called perivitelline space, which contains fluid and in which the Fig. 13. — Graafian Follicle. High power. In the center of the drawing is a folUcle undergoing development. In the center of the follicle is the ovum, which is surrounded by layers of cells constituting the membrana granulosa. The theca foUiculi is not differentiated as yet. To the lower left side are two primordial follicles. egg enjoys a free movement. As the follicle develops the crescentic lake con- taining the liquor folliculi becomes more and more filled with fluid, which forms from a transudation of the vessels of the theca and from vacuolization of the granulosa cells. It is a thin serous fluid containing albumin and is undoubt- edly a source of nourishment for the egg. The egg surrounded as it is by several radiating layers of granulosa cells (the discus proligerus) does not come in direct contact with this fluid, but evidently receives nourishment from it through the medium of a fine intercellular network (paladinos), the fibrils of which reach the zona pellucida. Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 37 The follicle as it grows larger recedes from the albuginea, and hes more deeply embedded than do the primordial follicles. When the changes described above are completed the follicle is said to be ripe, and at this stage it is termed a Graafian follicle. Up to the time of the menopause follicles in all stages of development, from the primordial to the rip- ened form, may be seen in the ovarian parenchyma. In all the follicles, even the smallest, numerous nerve-fibers accompany and surround the capillary vessels, esctending to the follicle epithelium and existing in small nodes in the membrana granulosa of the larger foUicles. Fig. 14. — Ripening Follicle fbom an Ovaby of a Woman of Twenty. (After Veit.) In some of the folhcles can be seen two and, rarely, three eggs. This appear- ance is usually seen in the unripe folhcles. It is not known whether this appear- ance represents twin eggs from the start, or whether it signifies a merging of two primordial follicles or a division of one foUicle. (3) The Graafian Follicle. —When the foUicle is ripe it moves slowly toward the surface and thins out the outer layer of the ovary. This pressure on the surface of the ovary creates a pale translucent spot, called the stigma, through which the egg is finally discharged. The internal force which serves to burst the foUicle is a subject of some debate. It is usually explained as follows: With the energetic development Digitized by Microsoft® 38 GYNECOLOGY of the vessels of the tunica externa there is a corresponding increase in the size and number of the cells of the tunica interna, which force themselves toward the center of the foUicle and gradually push the prohgerus with its egg toward the stigma. The internal force is also enhanced by the gradual increase in the amount of hquor m the follicle, especially during the menstrual congestion. Corpus Luteum.— When the foUicle has ruptured and the egg discharged the formation of the corpus luteum begins. The center of the collapsed follicle soon fills with blood, which issues partly from the vessels of the theca and Fig. 15. — Graafian Follicle. Surrounding the follicle can be seen the two connective-tissue envelopes, the outer (theca externa) being fibrous in character and the inner (theca interna) being more cellular. The egg is seen jutting out into the clear space surrounded by a mass of epithelial cells, the discus (or cumulus) proligerus. The several layers of epithelium lining the follicle constitute the membrana granulosa. The crescen- tic clear space is filled with serous fiuid, the liquor foUiculi. (After Veit.) partly from the small wound in the stigma. In animals this blood coagulum is not always seen, but it is practically constant in the human corpus luteum. Around the central blood-mass is the wrinkled yellow membrane which characterizes the corpus luteum by its unique color. There has been some question as to the origin of the cells that make up the yellow membrane, but it is now generally accepted that they represent the hypertrophied epithelial cells of the membrana granulosa. They are large and polymorphous, with a large nucleus, and resemble somewhat decidual cells. The cell-body contains drops of fat and yellow pigment granules that give the characteristic color. Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 39 These are the so-called lutein cells. Into this lutein layer sprout blood-vessels and connective-tissue radial projections, which vascularize and support the corpus luteum. The resultant picture of large epithelial cells, with pale stain- ing nuclei lying in contact with small thin-walled blood-vessels, corresponds to the structural appearance commonly regarded as characteristic of organs of internal secretion. As will be seen, this is one of the arguments for the belief that the seat of the internal secretion of the ovary is in the corpus luteum. Fig. 16. — Gbaafian Follicle as it Appears in the Subbounding Ovabian Tissue. Just below the follicle is a corpus albicans. After the corpus luteum reaches the height of its development it gradually shrinks. The yellow coloring matter is absorbed and the lutein cells degen- erate in hyalin masses, held together by strands of connective tissue. The hyalin colorless masses then roll together in cloud-like convolutions and form the corpus albicans. This process of regression occupies about four weeks. The corpus albicans may remain a long time, but the hyalin material is event- ually entirely absorbed and all trace of the former corpus luteum disappears, excepting the scarred indentation on the surface of the ovary. The size of the corpus luteum varies considerably, reaching sometimes even Digitized by Microsoft® 40 GYNECOLOGY in non-pregnant women a diameter of 2 cm. If pregnancy occurs its develop- ment is more pronounced, reaching its height about the second month. From the third month its regression is very slow, so that it is sometimes demon- strable at the end of pregnancy. If pregnancy is not present, the corpus luteum regresses rapidly and is usually shrunken by the end of a month. Follicle Atresia. — In the thirty to thirty-five years of menstrual hfe about fourteen to eighteen follicles reach full maturity each year, making a total of Fig. 17. — Graafian Follicle, Well Advanced. 400 to 600 during a life time. Inasmuch as there is an original endowment of about 30,000 folhcles at birth, only a small percentage of them develop com- pletely, the remainder becoming aborted during some stage of their develop- ment, a process that is called atresia of the follicle. This process must be re- garded as a physiologic one, beginning as it does in the newborn and probably in the mature fetus and lasting until the menopause. The cause of atresia is thought to be some insufficiency of the local blood- Digitized by Microsoft® PHYSIOLOGY OF THE UTERUS AND OVARIES 41 supply, or a too deep embedding, which may be unfavorable for the bursting of the foUicle. Follicle atresia takes place in the following way: The egg slowly undergoes a fatty degeneration and becomes hquefied. The granulosa cells also degenerate by the process of vacuolization and fall into the central cavity of the follicle. The entire follicle collapses and assumes an irregular contour. At this stage the cells of the tunica interna begin to grow Fig. 18. — Graafian Follicle. Low power. This shows the edge of a fully developed follicle. The upper left part of the draw- ing is the cavity in the follicle. At the lower right edge projecting into this cavity is the cumulus proligerus, consisting of cells from the membrana granulosa, which lines the cavity, in the center of which is the ovum. At the bottom of the drawing can be seen a small section of ovarian stroma. Between this and the follicle is the connective tissue of the theca foUiculi. and assume an epithelioid type, resembling closely the lutein cells of the mem- brana granulosa. This theca membrane may become quite thick and wavy, hke that of the granulosa. As in the true corpus luteum there is a vascu- larization and connective-tissue formation, so that the resulting picture is the same as that of the corpus luteum, the essential difference being that the lutein cells are of connective-tissue origin, and not epithelial. Folhcle atresia is especially marked during pregnancy. During this period there is no actual ovulation, so that most of the more mature follicles become atretic. Digitized by Microsoft® 42 GYNECOLOGY It is said that during pregnancy there takes place in the theca lutein cells of the atretic follicles not only hypertrophy but hyperplasia, and that the cells acquire more fat and lutein than is seen in the non-pregnant state. In chorio-epithelioma and tubal gestation they sometimes form definite cysts which later disappear. In some species of animals the collections of theca lutein cells embedded in the stroma form a constant picture. These masses of cells have been called Fig. 19. — Corpus Luteum. Low power. At the top is the center of the corpus luteum, the edge seen being the edge of the blood-clot. Extending into this blood-clot are seen the pyramids formed of lutein cells, giving the edge of a corpus luteum its characteristic ruffled appearance. Between these two layers is a thin layer of connective tissue. Below the layer of lutein cells — that is, around the outside of the corpus luteum — is the theca externa, which contains many blood-vessels. the interstitial gland, and correspond, as said above, to the lutein cells of the atretic foUicles. They are thought by some to play a part in the manufacture of the internal secretion of the ovary. Two forms of follicle atresia are distinguished — the obliterating and the cystic. Cystic formation in the ovaries is, therefore, physiologic. The cysts, however, may grow to an abnormal size and become of pathologic significance. (See Retention Cysts.) Digitized by Microsoft® 4-"' ■Li& • \ ^V .V ( .-■ I ^' ..if .V ~\ ^\. ,./ ■ ,-<>■: .,.'f '■ ;■''' #y^. -' . ,4 '-. -. •,-*% , >: ^^.5.. \: -I-; 'f^ '•<'■ -. ' ^■/- '- <:^ '^: ..■-;> ^^ A cc'Txprc Fig. 19a. — Corpus Ltjteum. _ Very low power. Around the .edge is the pHcated envelope of lutein cells. The center is occu- pied by coagulated blood, around the edge of which the lutein cells are proliferating. Organization of the blood-clot is going on. Fig. 20. — Wall op Corpus Lutbum. High power. This shows the pigment found in the lutein cells, which gives them their distinctive yellow color. It is derived from the blood extravasated during rupture of the follicle. 43 Digitized by Microsoft® Relationship of gynecology to the general Organism relationship of gynecology to the glands of internal secretion Glands of internal secretion are ductless structures which, by the agency of certain differentiated cellular elements, manufacture substances that are absorbed directly into the blood-circulation. The knowledge of the physiology and pathology of these glands is comparatively recent and is at the present time very incomplete, but the importance of their relationship to the general organism, and especially to the genital system, is widely recognized. Many of the results gleaned from experiment in this new hne of research are contra- dictory, and the subject is, therefore, in a state of much confusion. Only those facts that are most convincing and most generally accepted will be given in this section. The glands of internal secretion comprise the hypophysis or pituitary body, the thyroid, the parathyroid, the adrenal, the pineal (epiphysis), and the sex glands. The islands of Langerhans of the pancreas are also included, for their function is internal secretory as distinguished from the acinous portion of the organ, which is provided with a duct, and is therefore excretory. The histologic type of internal secretory structure consists of relatively large, pale, not sharply defined epithelial tissue, containing a rich network of capillary blood-vessels, which carry off into the circulation the products of the cell activity. The substances secreted from these glands have a very im- portant influence on the general organism of the body and are in some instances necessary to life. It has been established beyond doubt that the ductless glands are normally so correlated as to form a perfect physiologic balance, which is preserved by a proper distribution of harmony and antagonism between the functions of the various glands. If one of the glands is diseased or injured or extirpated, the normal balance is upset and the organism of the individual may be affected by the abnormal action of one or more distant glands of the group. OVARYi That the ovary is a true organ of internal secretion is proved by very sub- stantial evidence gained from observations made after removal, and from transplantation of ovarian tissue, and by the effects of the injection into the tissues of ovarian substance. Castration before sexual maturity causes a failure of genital development, while in adult life it produces immediate 1 Some of the material in this section is taken from an article by the author, published in the American Journal of Obstetrics, 1913. 44 Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 45 regressive changes in the uterus, vagina, and external genitals, manifested by well-marked atrophy of the parts. It has been shown by animal experimenta- tion (Halban) that this genital atrophy can be inhibited after castration by transplanting the extirpated ovary in distant parts of the body, and if this operation is done on young animals the other genitals may develop normally. It has also been shown in animals that castration prevents rut, but that later implantation of ovarian tissue may reproduce the manifestations of rut (Halban) . An observation of much practical importance (as we shall see later) shows that the injection of ovarin in virgin animals creates changes of hyperemia and secretion in the internal and external genitals similar to those which occur during rut. These are only a few examples of numerous experiments that prove the existence of an ovarian internal secretion. The exact nature of the ovarian secretion has not been determined, nor is it conclusively known in what part of the ovarian tissue the substance is manu- factured. There are three anatomic structures of the ovary from which it might reasonably be supposed hormones could be elaborated — the follicle apparatus, the corpus luteum, and the interstitial gland. Inasmuch as an ovarian secretion is known to exist before puberty, as proved by the changes in development from castration in childhood, it seems hkely that the follicle apparatus must be the seat of manufacture, for the corpus luteum does not appear normally until sexual maturity. It is probable, there- fore, that the follicle apparatus presides over the growth and nutrition of the geni- tals (Frank). In addition to the foUicle apparatus, the corpus luteum has been shown to be the probable seat of manufacture of important ovarian secretion. As has been described in detail (see page 38), the corpus luteum forms within the foUicle cavity after the discharge of the ovum, and is derived from the epithehal (granulosa) cells lining the follicle. In its full development the corpus luteum presents the characteristic picture of an internal secretory gland, with large pale cells lying in close proximity to thin-walled blood-vessels, an appearance much like that of the adrenals. The corpus luteum does not develop until the age of puberty, and coincident with its appearance come the cycHcal changes of menstruation and the possibility of fecundation, phenomena which disappear after the cessation of corpus luteum formation at the chmac- teric. Experimental evidence supports the theory that the corpus luteum is an organ of internal secretion, and it is now generally conceded that its function is that of controlling menstruation' and of preparing and sensitizing the endo- metrium for the reception of the impregnated ovum. There is evidence from animal experimentation and clinical experience to show that the integrity of the fertilized ovum for the first few weeks of preg- nancy is dependent on the presence of the corpus luteum, Frankel having shown that its ablation at that period causes abortion in animals. Digitized by Microsoft® 46 GYNECOLOGY The general and local changes during pregnancy are probably controlled to some extent by the persistence of the corpus luteum, but, as Frank has pointed out, the persistence of the corpus luteum on the other hand is itself maintained by the products of conception, which doubtless share in causing the various manifestations of pregnancy. The interstitial gland is found in only about one-half of mammals examined as compared with the corpus luteum, which occurs universally in all mammals.^ Its structure is somewhat doubtful, but is usually thought to represent col- lection's of theca lutein cells from atretic follicles. It appears- only occasionally in human ovaries, Frank having seen it only once in a very large series of ovaries examined. The part played by the interstitial gland in the production of ovarian internal secretion is at present only a matter of conjecture, though it may in the human species share with the follicle apparatus some control over the development and nutrition of the genital organs. Objection has been raised to the possibility of the interstitial gland being an organ of internal secretion from the fact that it is composed of connective tissue cells, whereas the typical internal glandular structure is epithehal. The present tendency is to regard connective tissue, especially the highly differentiated form found in the stroma of the ovary, as possessing the possible power of internal secretion (Novak) . Clinical manifestations, of disturbances of the glands of internal secretion are caused either by deficient activity (hypofunction) or by an abnormal in- crease of activity (hyperfunction) of the glandular secreting substance. Under hypofunction must be considered not only the effects of diminished secretory power, but also the results of complete destruction or extirpation of the organ. In studying the effects of the removal or destruction of a given ductless gland one nmst take into account not only the influence of the loss of its specific secre- tion on the organism, but also the changes wrought in the other members of the group, the balance of whose function has thus been disturbed. Hypofunction of the Ovary. — We have seen that early castration prevents normal development of the genital system. It also produces changes in some of the other ductless glands, the most notable being that of the hypophysis, in which there takes place an increase in the size of the anterior lobe. The- hyper- trophy of the anterior lobe causes certain skeletal deviations that characterize the individual as of the eunuchoid type, by the accumulation of fat and by long extremities. "^ The interstitial gland is most pronounced in rodents, insectivora, chiroptera, and animals of prey. It is most apparent in early youth. With the appearance of the first corpus luteum the inter- atitial gland decreases, so that there seems to be a certain reciprocity between the corpus luteum and interstitial gland, which, as stated above, is derived from the theca interna cells of the atretic foUiole. Good development of the interstitial gland in these animals is apparently associated with good fertility. ^ In animals that bear many j^oung at the same time the interstitial gland is found highly organ- ized at the age of sexual maturity, whereas in animals, like man, monkeys, and the hoofed animals,' the gland is found pooriy dcA-eloped. In the latter case the gland is rudimentary at its best, and dis- appears completely after the appearance of the first corpus luteum (Aschner) Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 47 Nearly all generalizations on this subject have been from observations of castrated males. In human beings information on this subject is gained chiefly from a study of the eunuchs of the Turkish harems and from a religious sect in Russia called the Skops. It may be said that the body length of individuals who have been castrated early in general exceeds that of the non- castrated, an observation which is familiar in animals also, as in the case of oxen, geldings, and capons. Tandler and Gross and others ascribe this fact to a delayed ossification of the epi- physeal joints, which produces not only an increase in growth, but a deviation from the normal body proportions. The result is that the individual produced by early castration is not of the infantile type, but, on the contrary, far removed from it. While we find in children a relatively long trunk and short extremities, and a proportionately large skull, with small face, we find in the castrated a marked increase in the length of the extremities and a skull relatively small in comparison with the face. These gross physical changes are constantly observed, both in man and in animals, and it is not surprising, therefore, to find that there also constantly exists an enlargement of the sella turcica, due to hjrpertrophy of the hypophysis. It is, therefore, seen that the genital glands may bear an antagonistic relationship to the hypophysis, and that the early removal of the inhibitory influence of the testis, or ovary, allows for an overdevelopment of the hypophysis with corresponding manifestations suggestive of giantism or acromegaly (Novak) . Whether the effect of early castration in the female is identical with that in the male in the human species does not seem to have been determined accurately. Infantilism. — The relationship between early hypofunction of the ovaries and hypoplasia or infantilism is a subject about which there is much doubt. It is probable that most cases of infantilism are the result of some other cause than primary ovarian deficiency. (See also section on Infantilism and Sterility.) Infantilism relates to arrested development of various parts of the body, and may manifest itself universally in all parts of the body (infantilismus universalis) or it may appear only locally (infantilismus partialis). The manifestations of the condition in which we are par- ticularly interested are those that are seen in connection with the abdominail and pelvic organs and with the external female genitals, for some of them are of great cUnical importance to the surgeon. Some of the familiar stigmata of the infantile or hypoplastic condition in the abdo- men are enteroptosis, abnormal mobility of cecum and sigmoid, prolapse of the kidney, pelvic kidney, short appendiculo-ovarian ligament, funnel-shaped appendix, etc. In the pelvis there are the congenital or developmental uterine malpositions of retroflexion, acute anteflexion, ante- flexion with retrocession, and procidentia, all of which may cause clinical symptoms. In addition to this are the anomaUes due to the failure of complete imion of the Mtillerian ducts, causing the various forms of uterus didelphys and atresia, some of which may result in serious surgical comphcations. It was formerly supposed that these manifestations of infantihsm were due to a deficient development of the ovary from the fact that the ovary is sometimes foimd hypoplastic. The present theory is that the local stigmata of infantilism, such as are seen in the genitalia, are merely manifestations of a general "hypoplastic constitution," and that hypo- plasia of the ovary, when it occurs, is only an incident and not a cause of the general condition. In the great majority of these cases the uterus is distinctly infantile, but the ovaries are either normal or actually larger than normal (excluding the occurrence of cystic degeneration or thickened albuginea). It is sufficiently evident, therefore, that infantihsm is not necessarily due to ovarian deficiency. On the other hand, fuU development of the secondary characters may occur even in the complete absence of the ovaries. This is most commonly observed in cases of deficient union of the MuUerian ducts in which, according to Burrage, the ovaries are completely absent in 18 per cent. In cases of absence of the vagina the ovaries are sometimes either absent or only rudimentary. Many of these women are in every other way fully developed sexually and are sought in mar- riage; hence, the not infrequent necessity of the operation for making an artificial vagina. A special form of hypogenitalism has been described by Tandler and Gross, and named Digitized by Microsoft® 48 GYNECOLOGY by them Eanuchoidism. Women of this type are often powerful, athletic, and well formed. They reach the age of puberty comparatively late and menstruate scantily at irregular, often long, uitervals. When young they have a tendency to fat accumulation. They reach the cKmacteric early, soon after thirty. They exhibit no abnormality of the genital organs, but are usually sterile or show hmited fecundity. Atrophy. — Although up to the time of puberty the ovaries seem to have but moderate local or constitutional effect, we find definite evidence to show that during the child-bearing and menstrual period of life the ovaries not only- exercise a distinct trophic influence over the uterus and external genitals, but they seem to play a certain more or less important part in the general chem- istry of the organism. This is best seen in the atrophy of the uterus and ex- ternal genitals, which takes place when the ovaries become atrophied or are removed after attaining the period of full maturity. When atrophy of the ovary takes place the organ becomes shrunken in size, the follicles cease to ripen, and degenerative changes appear in the folUcle apparatus. The condi- tion when complete is manifested by amenorrhea. The uterus becomes small and flaccid, the cervix is shrunken and flattened. The labia become less full and rounded, the minora are slender and less prominent, and, finally, disappear entirely. The vaginal and vulvar mucous membrane is pale, inelastic, and contracted, and may give rise to most distressing symptoms. Physiologically, ovarian deficiency appears at the menopause and during lactation. According to Thorn, lactation-atrophy of the ovaries with secondary atrophy of the uterus is a constant phenomenon in nursing women. Frankel describes it as appearing during the third month after childbirth, and as disappearing in the seventh month even if the mother continues to nurse. Foges has shown that this atrophy is due to a cessation of the function of the ovaries and not to the nursing of the mother. Pathologic ovarian deficiency, as indicated by secondary atrophy of the other genitals, is said to follow local pelvic conditions of inflammation and tumor formation, but this is rare, for in most cases the ovarian tissue con- tinues to functionate even though only a very small portion is left by the dis- ease. Ovarian atrophy sometimes follows infectious and constitutional dis- eases, such as scarlet fever, articular rheumatism, diseases of the thyroid, anemias, paralyses, etc. (See section on Genital Atrophy.) Functional Amenorrhea. — The amenorrhea, or oligomenorrhea, that is seen in fully developed women, who have previously menstruated normally, is accounted for as a result of functional ovarian deficiency, a theory that finds strong confirmation in the almost immediate beneficial effect which ovarian extract usually has on these cases. Burnam describes an ovarian deficiency which manifests itself in women of the fourth decade of life by lassitude, depression, and general ineffectiveness, a condition which he has been able greatly to benefit by the administration of large doses of corpus luteum extract. Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 49 How far sterility and dysmenorrhea are caused by hypofunction of the ovaries has not been determined. Ovarian extract has little or no influence on these conditions. The influence of castration after maturity has been extensively studied, but at the present time no very important results have been gained. Schickele has observed an increase in the arterial tension following the artificial and natural menopause, and regards the effect as due to the loss of the depressor influence of the ovarian secretion. His observations have not been confirmed. Variations in sugar assimilation, coagulation time of the blood, blood- picture, chemical composition of the blood, reaction to drugs, etc., have been described, but cannot be detailed here, as in our present state of knowledge they are of minor importance to the practical gynecologist. It is probable that many of these changes are the result of disturbing the balance of the other ductless glands, and that the abnormalities are produced by the internal secre- tion of organs whose influence on the general metabolism is more powerful than that of the ovary. Some of the changes said to take place after castration have been greatly exaggerated. An example of this is the accumulation of fat almost universally beheved to be inevitable after the removal of the ovaries, and supposed to be due to deficient tissue oxidation from the loss of ovarian secretion. It is, however, the observation of pelvic surgeons of wide expe- rience that castration of adult women is not followed by a greater tendency to adiposity than is any other abdominal operation. Another fallacy in regard to castration is the behef that definite and often serious psychoneurotic symptoms are to be expected as a sequel of removal of the ovaries. This subject is treated in detail in the section on Neurology (see page 99). Suffice it to say that experience proves that there is no specific psychic or neurotic reaction following castration of the adult if properly per- formed, but, on the contrary, if the operation relieves the irritation of pelvic pain, even serious nervous conditions may be promptly cured. The most definite reaction that takes place after castration is shown in certain vasomotor disturbances, manifested by hot flushes, sweats, dizzy feel- ings, etc. These appear in about 80 per cent, of women upon whom hysterec- tomy has been performed somewhat irrespective of whether ovarian tissue has been left or not. The exact cause of these vasomotor appearances has not been determined, but that they are at least partly due to the removal or disturbance of the ovarian secretion is made probable by the almost invariable rehef from them gained by the administration of ovarian extract. The subject of vasomotor disturbances following the artificial and natural menopause is more fully discussed in the section on Neurology (see page 91). Hyperfunction of the Ovary.— Our present knowledge of the influence of hypersecretion of the ovary is very theoretic and not suSiciently well founded on scientific facts. Abnormal activity of the gland is supposed to be mani- fested by menorrhagias and possibly by premature sexual development and Digitized by Microsoft® 50 GYNECOLOGY overfertility. From a, clinical standpoint, the most important phase of the question is that which applies to those cases of uterine bleeding which cannot be satisfactorily explained on an anatomic basis. This includes cases even when certain demonstrable anatomic changes are associated with the bleed- ing, such as myomata, chronic endometritis, glandular hypertrophy, chronic metritis (increase of connective tissue), chronic oophoritis, small cystic de- generation of the ovaries, etc.^ It also includes those baffling cases of so-called uterine insufficiency in which there is severe menorrhagia without macroscopic or microscopic change in the tissues of uterus or adnexa. 1 Schickele and Keller, in an article (Arch. f. Gyn., 1912, Bd. 95, Heft 3) entitled "On So-called Chronic Metritis and Small Cystic Degeneration of the Ovaries; Their Relation to Uterine Bleeding," have supplemented their work on the relationship of the glandular changes of the endometrium to uterine bleeding. These investigators undertook to verify the theory of Theilhaber that the bleeding from cases of uterine insufficiency is due to an abnormal disproportion between the connective tissue and muscle-fibers of the uterine wall. In a very laborious piece of work they took sections from the myometrium of a considerable number of extirpated uteri. The sections were stained by the Van Gieson method and projected on millimeter paper, on which drawings were made of the connective tissue. In this way a fairly accurate calculation was made of the amount of connective tissue rela- tive to the muscular fibers. Their calculations led them to conclude that uterine hemorrhages had nothing to do with the amount of connective tissue in the myometrium. Hemorrhages may occur with an associated hypertrophy of the connective tissue, or they may occur with a perfectly normal amount of connective tissue. On the other hand, abnormal bleeding may be entirely absent in association with great overgrowth of the connective tissue. The same two investigators studied the ovaries of 7 cases of uterine insufficiency in which the uterus and adnexa had been extirpated, and found no characteristic anatomic changes in the follicles, connective tissue, blood-vessels, or albuginea, to which abnormal uterine bleeding could be assigned as a cause. The careful studies of Schickele and Keller of the relationship between endometrium, myome- trium, and ovaries, with abnormal uterine bleeding, are worthy of especial attention. Their general conclusions may be summed up as follows: The idea that bleeding and leukorrhea are cardinal symptoms of so-called endometritis (gland hypertrophy) must in the future be modified. It is well established that severe hemorrhages may take place both during and outside of menstruation without the slightest change in the endometrial glands; on the other hand, marked conditions of gland hyperplasia may exist without any abnormal bleeding. There can, therefore, be no essential connection between abnormal uterine bleeding and changes in the endometrial glands. Although uterine bleeding and gland hyperplasia may exist at the same time, there is no reason for declaring that the bleeding is caused by the glandular condition. There is no anatomic characteristic change in the mucous membrane, which, as such, calls forth hemorrhage or leukorrhea. The same thing may be said with regard to so-called chronic metritis (increase of connective tissue). There is, as a matter of fact, a true metritis, which depends for its origin on bacterial infec- tion, and which on healing develops certain anatomic changes, but we have no proof how often this form occurs, what its anatomic characteristics are, and whether there exists any connection between it and uterine bleeding. Hyperplasia of the connective tissue cannot be looked on as an expression of such a chronic metritis any more than can the dilatation of the blood-vessels, which is also present. It is certain that a hyperplasia of the uterine connective tissue does not necessarily produce abnormal bleeding. If there were any such connection between the two, we should have abnormal bleeding with every case of connective-tissue hyperplasia, and the greater the hyperplasia, the more intense would be the bleeding. This is not the case. Those cases in which, in spite of' a normal amount of connective tissue, and, therefore, well-developed musculature, intense hemorrhages occur, make it still clearer that the real etiologic factor is something different and more important. Everything forces us to the conclusion that the causes of abnormal uterine bleeding must be sought elsewhere than in the anatomic changes of the uterus. We naturally turn next to the ovary as the organ which would be most likely to influence the uterus. In the ovary anatomic changes can be demonstrated which may occur simultaneously with atypic uterine bleeding. However, it is an established fact that these same atypic bleedings may take place without any demonstrable anatomic change in the ovaries. This fact leaves the significance of the above-mentioned changes of the ovaries in a very uncertain light. We do not even know whether the functional processes in the ovary express themselves in its anatomic structure; whether any anatomic changes of the ovaries signify the outer sign of functional disturbances. Under such conditions the reputed significance of chronic oophoritis or of small cystic degeneration falls to the ground. We have at present no clue by which we can judge the function of the ovary by its anatomic appearance. Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 51 The belief that most uterine bleeding is the result of a hypersecretion of the ovary is based on the theory of interrelationship between ovarian secretion and menstruation, the course of reasoning being as follows: The functions of the uterus are under the control of the ovaries, for without the ovaries there is no true menstruation. During menstruation the blood-vessels of the uterus, and especially of the endometrium, are always dilated and the normal menstrual blood is uncoagu- lable. It is supposed, therefore, that there is manufactured in the ovaries as an internal secretion a substance which passes over into the uterus in the blood, and which, when enough of it has accumulated, produces the phenomenon of menstruation by dilating the capillaries of the endometrium and reducing the coagulabihty of the blood. The substance (probably by chemical influence) acts on the walls of the small blood-vessels of the endometrium, causing a hyaline change which makes them more permeable for the passage of the blood. The menstrual bleeding stops when the active substance which causes dilatation of the blood-vessels and non-coagulability of the blood is eliminated by the flow. The ovaries continue to manufacture the substance, which in turn continues to flow over into the uterus until enough is accumulated to produce again the menstrual discharge. By this theory, therefore, abnormal uterine bleeding is easily explained by the storage in the uterus of an excessive amount of ovarian secretion. This theory is not without scientific substantiation. Of very great interest are the experi- ments of Schickele on the influence of uterine and ovarian extracts on the time coagulabihty of the blood. He made extracts of the uterus, endometrium, and ovaries that had been removed for various causes at surgical operations, and, adding them to combinations of animal blood- serum and plasma, observed the changes in the time of coagulation as compared with normal controls. From these investigations he proved that extracts of the uterus and ovaries delay the coagulation. In those cases where the extracts were made from organs in which abnormal bleeding had not existed he found that the ovarian extract caused a greater delay than did that from the uterus. In those cases where there had been severe menorrhagia or other hemor- rhages, the effect of the uterine extract was more powerful than that of the ovaries. More- over, he showed in these cases that the extract from the endometrium was more powerful than that from the myometrium. The general conclusion was that extracts from organs in which the menstruation had been unduly prolonged caused a greater delay in blood coagulation than did the extracts from organs where menstruation had been normal. The conclusion from the foregoing is that in the ovaries is produced a sub- stance that is passed over to and stored in the uterus and endometrium, which has the power of local dilatation of the blood-vessels and of delaying or pre- venting the coagulation of the blood. Hyperfunction of the ovary causes an oversupply of secretion, and thus brings about increased or prolonged men- strual flow. Ovulation and Menstruation.— It has long been a mooted question as to whether a definite relationship exists between the time of ovulation and men- struation. Observations on this point vary considerably in the study of the human ovary chiefly on account of the difficulty in determining the exact age of the corpus luteum. In order to faciUtate the accumulation of evidence on this subject Frank has epitomized his own work and that of others in an excellent description of the macroscopic and microscopic appearance of the corpus luteum in its various stages. The reader is referred to this article for the microscopic details (Surgery, Gynecology, and Obstetrics, Nov., 1914). In this Digitized by Microsoft® 52 GYNECOLOGY review the life of the corpus luteum is divided into four stages, the macroscopic appearances of which are herewith given verbatim in order to aid the operator who wishes to make a series of observations of his own: (a) Proliferative Period.— Macroscopically, immediately after ovulation the ruptured foUicle appears as a small, flaccid, collapsed vesicle. This lack of prominence accounts for the fact that numerous investigators have overlooked the earUest stage. Confusion has also arisen from the gross and also microscopic resemblance of the atretic foUicles to early corpora (b) Vascularization.— Macroscopically, the corpus luteum appears as a typical bluish-red prominence on the surface of the ovary. It is indistinguishable from the later stages. On cross-section more often than at a later period the central coagulum is flmd or jeUy-like in consistence and its center may be freed from blood, but no absolute diagnostic value can be accorded to these differences. j-rc c (c) Period of Ripeness.— Macroscopically, the external appearance does not differ from that of the just vascularized corpus luteum. On cross-section, especially toward the end of this stage, the central coagulum may be firmer, and a well-defined yellowish-brown crenated margm (the lutein edge) may surround the clot. Not infrequently the center of the corpus luteum is cystic. (d) Period of Regression.— Macroscopically, the corpus luteum looks paler. On cross-sec- tion the centrum is more sohd and colorless ; instead of this, the center may remain cystic. The crenated margin is of brighter yellow color, broad, and well defined. (e) Corpus Luieum of Pregnancy .—M acroscopically , it is often larger than the corpus luteum of menstruation; but it cannot be differentiated from it with any degree of certainty. Though a definite time relation between ovulation and menstruation is no longer disputed, the exact period of the relationship has not yet been deter- mined. Various estimates have been made, but, according to Frank, we are justified in the present state of our knowledge in "concluding merely that ovu- lation follows menstruation and that the fertihzed ovum (impregnation) dates from before the missed period." There is evidence to show that impregnation usually dates from within the first week following menstruation, and that the optimum time for fertilization is immediately after the menstrual period. Meyer and Ruge have described the relationship between ovulation and menstruation as follows : "In the 2S-day cycle of menstruation the ripening of the foUicle probably comes after menstruation on about the eighth day from its beginning, if not during the time of menstrua- tion itself. The beginning of lutein formation is the second week; then the hemorrhage fol- lows in the second half of the third and in the fourth week. The height of the hemorrhage fol- lows in the second half of the third and in the fourth week. The height of the hemorrhage is immediately preceding menstruation. During the latter regression begins and lasts about fourteen days. The normal sequence is then as follows: first, the hyperemio stage of the corpus luteum during the interval; the stage of vascularization of the corpus luteum at the beginning of the premenstrual phase; hemorrhage of the corpus luteum in the advanced premenstrual phase; the high point of hemorrhage of the mucosa and of the corpus luteum shortly before menstruation; and the regression during and after the same. During pregnancy the corpus luteum remains at the high point of its hemorrhagic state.'' Ovarian Transplantation. — It has been repeatedly shown by experimen- tation that transplantation of an ovary or piece of ovary after castration will maintain for a time the function of menstruation, while in animals it has Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 53 been demonstrated that for a time after implantation the folHcles continue to ripen as they do in the normally placed ovary. Several cases of impregnation have occurred after implantation of ovarian tissue in the tubal angles of the uterus. Franki and Halliday-Crom^ have each reported a case of pregnancy and full-term child after such an operation. In the latter case the ovary transplanted was from another woman. A number of cases of abortion after ovarian transplantation for the purpose of fecundity after extirpation of the tubes have been reported, many of them lacking complete confirmation. (See also section on Sterility.) Organotherapy. — The therapeutic value of extracts of ovarian substance has passed beyond the stage of theory and speculation and is now an estab- lished fact beyond all doubt. With regard to the nature of the active sub- stance, the exact location in the ovary of its manufacture, and many other questions we are still considerably in the dark. The earher reports of the use of ovarian extracts were, for the most part, discouraging, but in recent years better preparations, a more definite knowledge of the physiology of the ovary, and a more intelhgent selection of cases for treatment have yielded results that are not only satisfactory, but often astonishing. , The value of ovarian therapy is seen in the treatment of patients who are suffering from functional deficiency or absence of the ovarian internal secretion. The most conspicuous examples of this are those who experience the vaso- motor disturbances of the natural or artificial menopause, the symptoms of which consist chiefly of hot flushes, vertigo, etc. By the administration of a properly prepared extract these symptoms are, with some exceptions, greatly benefited or made to disappear entirely. The extract is, therefore, of the greatest help in the routine postoperative treatment of patients who have under- gone hysterectomy, at least 80 per cent, of whom suffer from vasomotor changes. Next to its importance in menopause cases is its value in treating young women with functional amenorrhea and oligomenorrhea. Its results with these patients are not as constant as in the first class of cases, but its use is here successful, either partially or completely, in the majority of instances. A third type of cases in which ovarian therapy is surprisingly efficacious is represented by patients suffering from deficient circulation of the external genitaha. As is elsewhere stated (see page 45), animal experimentation has proved that the ovarian internal secretion has a specific hyperemic effect on the external genitalia. Substantiation of these experiments on animals is seen in the beneficial effect which ovarian extracts have on the conditions of pruritus, kraurosis, furunculosis, and other affections of the vulva in elderly women where the local disturbance of the parts is due to inadequate circulation. Aschner has been able to produce hemorrhage and even hematometra in guinea-pigs by the injection of ovarian extract. He finds in animals thus treated that the ovaries contain an un- usual number of ripening foIHcles, and ascribes to this phenomenon the hemorrhagic congestion 1 Zentralbl. f. Gyn., 1898, p. 444. ^ Edinburgh Obstetrical Soc, 1905. Digitized by Microsoft® 54 GYNECOLOGY of the uterine mucosa and the hyperemia of the external genitals. Aschner has also found that placental extracts work still more strongly than ovarian extract, and suggests that they be used in amenorrhea, sterility, and cUmacteric disturbances. In the treatment of the foregoing classes of cases the evidence of the value of ovarian organotherapy is beyond dispute, and is entirely substantiated by a large experience in its use by the author. In addition to these three types, various other gynecologic affections are reported to be greatly benefited by ovarian extract. Burnam has had marked success in treating neurasthenic under-par women in the preclimacteric decade. Dannreuther reports success in bringing a patient to term after repeated abor- tions, and finds the treatment helpful in the hyperemesis of pregnancy. A few cases have been reported of the cure of sterility, but its efHcacy in this respect is extremely doubtful. In conditions presumably due to hypersecretion of the ovaries and menor- rhagia, as one would expect, organotherapy is of little assistance. There is at present much discussion and experimentation in the matter of the form of the extract. On the almost universally accepted theory that internal secretion of the ovary is manufactured by the corpus luteum, most extracts nowadays are made from the yellow body of either pigs or cows. On the ground that the corpus luteum of pregnancy is more stable than that of ovulation, it is considered by some (Dannreuther) of the greatest importance that the preparation be made from pregnant animals. On the other hand, the author, whose results compare favorably with those of the most enthusiastic users of the corpus luteum, has employed an extract from the entire fresh ovary which he has found equal in effect to the lutein extracts. The use of ovarian extracts is not dangerous, there being no toxic effects excepting a slight disturbance of the stomach. Dannreuther lays consider- able stress on the depressing effect of continued doses on the blood-pressure. This is probably more noticeable in the case of corpus luteum extract than in that of the whole ovary. The dosage is the same whether corpus luteum or ovarian extract is given, 6 gr. three or four times daily. In most of the preparations now used 1 gr. of the extract represents 6 or 7 gr. of the fresh ovarian substance. It is of absolute importance that the preparation be fresh, the use of stale extracts probably accounting for many of the unsatisfactory results reported. It is quite probable that with a better chemical knowledge of the ovarian substance, and with improved methods of preparing and administering the extracts, there will in time be a notable advance in the use of this already in- valuable remedy. There is no doubt that in the change from the ovaries to the commercial extract important ingredients of the ovarian secretion are dis- turbed. That only a part of the full effect of the secretion is reproduced is shown by the fact that whereas ovarian therapy is eminently successful in treating disturbances of the menopause, it has no effect on stopping uterine Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 55 atrophy. Moreover, it must be remembered that while in the body the ovarian secretion passes directly into the circulation, ovarian therapy requires that the substance pass through the digestive apparatus, so that a chemical dis- turbance in the secretion is more than probable (Bab). THE HYPOPHYSIS The relationship of the hypophysis to the genitalia is one of especial inter- est, and one which has been somewhat more definitely established than has the connection between the generative organs and the other glands of internal secretion. The first knowledge of this subject dates from the discovery of anatomic and physiologic changes observed in the pituitary body during pregnancy. Tandler and Gross (1908) called attention to the similarity of the facial changes often seen in pregnant women to those seen in acromegaly, and ascribed this appearance to an increased activity of the pituitary gland. Erdheim and Stumme made a systematic study of the hypophyses of women who had died during pregnancy, and proved that the gland always becomes hypertrophied during the pregnant state. They showed that the hypertrophy takes place only in the anterior lobe, and that the posterior lobe not only does not share in the overgrowth, but actually suffers a certain amount of compression. After childbirth the gland undergoes a partial but not complete involution to its former size. The anterior lobe is altered both in color and consistency after the first half of pregnancy. The histologic changes are very constant and characteristic, and consist of a well-marked difference in the size and numeric distribution of the three types of cells which make up the body of the gland. These microscopic changes do not entirely revert to the normal condition until several years after gestation. The effect of removal of the hypophysis has been demonstrated by a number of experimenters, notably Gushing, Biedl, and Aschner: Gushing found in animals from whom the anterior lobe ot tne hypophysis had been removed a characteristic picture. The animals grew very fat, the genital organs of adult animals becoming atrophied, and those of young animals remaining undeveloped and infantile in type. In time there ensued polyuria and glycosuria, falling out of the hair, subnormal temperature, and lessened resistance to infectious diseases. Aschner's experiments consisted of total and partial extirpations of the gland in dogs before and after sexual maturity, with the purpose of noting the anatomic changes in the reproductive organs. The operations on the hypophysis were made by the oral route, through the soft palate and cuneiform bone. The dogs which had been operated on before sexual maturity were al- lowed to live until several months after the time of normal maturity, and were then compared with normal control dogs of the same litter. The experimental animals showed the character- istic outward disturbances of development described by Gushing, manifested by retarded skel- etal growth, accumulation of fat, and general infantilism of the various organs, the internal gen- ital apparatus being small and underdeveloped. Histologic examination of the ovaries showed retarded and incomplete ripening of the follicles and a special tendency to cystic degeneration. The uterus remained hjrpoplastic and infantile in character. Heat appeared later in these Digitized by Microsoft® 56 GYNECOLOGY dogs than in the normal, and only in rudimentary degree, with slight appearances of hyperemia and uterine secretion. There was invariably sterility and only faint manifestation of sexual impulse. Extirpation of the hypophysis in mature animals showed less marked changes in the genital organs. A moderate amount of degeneration was observed in the ovaries, while the uterus showed very much less atrophic change than is seen after castration. Heat was not entirely destroyed, but was considerably weakened. The effect of removal of the hypophysis on pregnancy was carefully studied. In order to remove the element of operative shook the operations on gravid animals were performed in two stages, the first consisting of opening through the bone and baring the diira, while in the second the gland was extirpated. Abortion invariably followed the second stage of the operation. Aschner finds less marked changes in the genital organs after his operations of extirpation than did Gushing and Biedl after partial removal. Aschner claims that the difference is due to the fact that by his special technic less injury is done to the brain substance than by Cushing's intracranial method, and calls attention to the fact that lesions of various portions of the brain, cerebellum, and spinal cord may produce results in the genital system similar to those caused by extirpation of the hypophysis. In human beings the relationship between hypophysis and the genital organs is manifested in a number of ways. Physiologically, the hypophysis shows most marked changes during pregnancy, as shown by the appearance of pregnancy cells of Erdheim and Stumme in the gland itself, and by the acromegaly-hke changes in the body of the pregnant woman. The complementary action between hypophysis and genitals is manifested by the effect of castration on the former. Fichera describes an enlargement of the hypophysis and hyperfunction after removal of the genital glands, and the effects of castration on young individuals are familiar, namely, the skeletal growth suggestive of giantism, the accumulation of fat, and the anomahes of skin and hair. Conversely, giants have certain resemblances in outer appear- ance to individuals who have been castrated when young (eunuchs), while their genital apparatus shows evidence of hypodevelopment and function in the form of impotence, amenorrhea, and sterility. Giantism results from hyperfunction of the hypophysis if the disturbance occurs before puberty. When hyperfunction of the pituitary gland takes place after puberty the result is acromegaly. Acromegaly in its earlier stages is often characterized by a stimulation of the genital system, which, however, in time gives way to impotence, amenorrhea, and sterility. The relation of the ovaries to the hypophysis is weU illustrated by the case reported by Goldstein of a woman, who in her youth had shown some tendency to giantism. At the Eige of thirty-eight she was subjected to a panhysterectomy for myomatous uterus. Soon after the operation she developed a very marked case of acromegaly. In this instance the influence of the ovaries had held in check the strong tendencies of the hypophyseal secretion. When the neutraUzing effect of the ovaries was removed the abnormal tendency of the hypophysis was manifested by the development of acromegaly. Hypof unction of the pituitary gland is usually caused by some form of pressure on the hypophyseal stalk through which the internal secretion is thought to enter the system. If this condition takes place before puberty, the Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 57 result is retardation in skeletal growth in the form of true dwarfism, in contra- distinction to giantism which follows hyperfunction before puberty. When hypofunction of the gland from whatever cause occurs after puberty there ensues a marked tendency to the general accumulation of fat associated with genital atrophy and diminution or absence of sexual function. This condition is termed "dystrophia adiposogenitalis," and is one of the most dis- tinctive clinical features of hypopituitarism, corresponding definitely to the appearances in the experimental dogs described above. Organotherapy.— Extract of the posterior, lobe of the hypophysis, pituitrin, has been found to be of undoubted value. Experimentation has shown that its physiologic action is to increase the blood-pressure, strengthen the heart action, increase the excretion of urine, and stimulate the irritabihty of the smooth muscles, especially of the uterus. Therapeutically, the extract is efficient in stimulating uterine contractions in child labor and in controlling bleeding in conditions of uterine atony. It has also been shown to be of use in atonic conditions of the bladder and in- testines in postoperative cases. Extract of the anterior lobe is recommended for the adipose type of genital atrophy. THE THYROID The variations in size of the thyroid gland during certain phases of the female sexual life has been observed since the earliest times, but only recently has the subject been put on a scientific basis by exact clinical observations and animal experimentation. It has been observed that at puberty the thyroid at times takes on a marked enlargement, which is much more intensive and much more common in girls than in boys, and it has been suggested that many of the puberty symptoms in girls, such as tendency to heart palpitation and the evidences of vasomotor disturbances, may be due to a hypersecretion of the gland at this period. Experiments have shown a certain antagonism between the ovaries and the thyroid gland. Animals that have been castrated early exhibit an abnormal length of certain bones, especially the tibia, while in animals from which the thyroid has been extirpated these same bones are excessively short. The early extirpation of the thyroid produces a certain amount of degenerative change in the ovaries or testicles, delays the time of puberty, and greatly hmits the productivity of the individual. It has been well established that the thyroid swells during menstruation, a phenomenon that has long been observed, and as proof that this is not due to hyperemia is adduced the fact that sometimes these menstrual swellings are the starting-point of permanent goiters. Women with diseased thyroids usually have menstrual disorders. Kocher has observed that patients on whom a too radical goiter extirpation has been Digitized by Microsoft® 68 GYNECOLOGY performed suffer from menorrhagia, and has treated such cases successfully with thyroid extract. He terms this condition vienorrhagia thyreopriva. That the relationship between thyroid and genitals is not understood is shown by the fact that in some cases of hypothyroidism, or myxedema, there is amenor- rhea, and that thyroid extract works beneficially for the conditions both of menorrhagia and amenorrhea when the gland is diseased. Interesting olinioal observations have been made which seem to show some definite con- nection between thyroidism and menstruation. Klokow reports the case of a seventeen-year- old sirl who whenever her menses were delayed, always developed a goiter, which immediately vanished as'soon as the period appeared. Steinberger reports the case of a girl of sixteen who suddenly ceased flowing during one of her periods and at the same time developed a goiter. Treatment with iodi,n caused the goiter to disappear, whereupon the menstrual flow was re- sumed. The swelHng of the thyroid gland is most noticeable during pregnancy, H. W. Freund having demonstrated it in 45 out of 50 cases. Lange regards the process as a physiologic one, and considers it due to hypertrophy rather than to hyperemia of the organ, because of its amenabiUty to iodin treatment. Lange also made the interesting observation that women in whom the thyroid does not swell exhibit a renal albuminuria, and expressed the behef that the swelling of the thyroid acts as a protection against certain poisons which are set free as a result of pregnancy, and which, without the protection of the secretion from the hypertrophied thyroid, are injurious to the kidneys. As a rule, the enlargement of the thyroid gland gradually disappears after the end of pregnancy, but not a few cases have been reported in which a perma- nently increasing goiter dated from a pregnancy. The thyroid swelling of pregnancy is ordinarily only very moderate, but several cases are cited in the literature by Novak where the goiter became so large as to threaten the patient's life, necessitating either a tracheotomy or artificial interruption of the pregnancy. During labor the thyroid is said to take on a still greater enlargement, which in a few cases has resulted in extreme dyspnea and death. The swelling of the gland gradually recedes after labor, though it has been observed to be maintained to some extent through the lactation period. The influence of the climacteric on the thyroid gland is little known, and the subject is largely a matter of speculation. Several instances of Graves' disease have occurred at the climacteric, and have led to the suggestion that the neuropathic and vasomotor symptoms of the change of life are the result of hyperactivity of the thyroid gland. The relationship between myomatous uteri and thyroid diseases was first remarked by W. Freund in a paper written in 1891. Many interesting observa- tions have been made on this subject, but the relationship cannot be very con- stant, as a coincidence of the two conditions is certainly not particularly com- mon. Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 59 Glaessner reports the case of a woman suffering from myoma and Graves' disease in whom both diseases disappeared at the climacteric, while Franliel cured a myoma and a goiter at the same time by the use of the x-rays. Franliel explains both these cases on the theory that both cures were due to the injury to the ovaries. The most recent theory connecting uterine myomata with the thyroid gland is that of Neu, who attempts to account for the heart lesions so often found in long-standing fibroid cases, a condition which he styles the "myom- herz." This myoma heart he regards as due to the effect on the heart of the thyroid disturbance with which myomata are sometimes associated. Hyperthyroidism. — Basedow's disease is about eight times as common in women as it is in men, and occurs chiefly during the sexual period of life. It is usually associated with a certain amount of atrophy of the genital organs, which is often manifested by amenorrhea and a tendency to sterihty. Sterility, however, is by no means constant, and when impregnation does occur it usually has a deleterious effect on the diseased thyroid. A few cases have been re- ported in which an intercurrent pregnancy has exerted a favorable influence on the disease, but the general experience is to the contrary. Exophthalmic goiter is frequently seen associated with gjmecologic dis- ease, such as misplacements, pelvic inflammation, etc., and the question of operation is a most important one. It may be said that the disease is some- times made worse by the shock of a surgical operation, and that, therefore, operative measures should only be undertaken in cases of necessity, or when it is obvious that the thyroid disease is being distinctly aggravated by the pelvic lesion. ' In one case in the author's experience in which there had been severe dysmenorrhea both the patient's general condition and the thyroid disease were distinctly improved by the opera- tion; in another case Graves' disease was not discovered until after the operation, which un- questionably aggravated the disease to such an extent as to make it definitely noticeable. To persons suffering from exophthalmic goiter the question of marriage and reproduction is an important one. It is necessary to take into considera- tion the undoubted fact that either the tendency to the disease or allied neurotic conditions may be transmitted by heredity, while the danger of aggravating the disease by pregnancy is a matter of moment. Hypothyroidism (Myxedema, Cretinism [Novak]).— Our knowledge of the resulting conditions of hypothyroidism is gained from animal experimen- tation, operations on human beings for goiter, and the clinical effects of absence or destructive disease of the thyroid gland. Removal of the thyroid of young animals produces constant and charac- teristic appearances, consisting of an immediate limitation of growth, especi- ally of the long bones, changes in the growth of the hair, lowering of the tem- perature, thickening of the skin, atheromatous changes of the aorta, genital hypoplasia, sterility, and idiocy (v. Eiselsberg). Digitized by Microsoft® 60 GYNECOLOGY In older animals the changes are somewhat less marked and are charac- terized by apathy, disturbances of the skin and digestion, emaciation, anemia, and lowered resistance to disease. The genital functions are diminished, but not always entirely destroyed. These experimental results in animals correspond very closely to the effects of thyroid removal in man, when all the gland structure (excluding the para- thyroid) has been extirpated. The condition has been termed "cachexia strumi- priva" (Kocher) and "postoperative myxedema." In the young complete re- moval brings about changes similar to those described in animals, sexual devel- opment being either entirely prevented or much delayed. Congenital myxedema or thyreaplasia relates to a condition where there is entire absence of the gland. The picture is characteristic and familiar — dwarf- ism, cretinic facies, peculiar thick, dry skin, broad nose, wide nostrils, and thick lips. There is very marked hypoplasia of the genital organs and mental defectiveness. This condition is said to be hereditary, being influenced by blood relationship or alcoholism of the parents. The disease does not make its appearance until the second half of the first year, it being supposed that in uterine life and during the lactation period the child receives thyroid secretion from its mother. Infantile myxedema is the result of an early atrophy of the thjToid gland in children who are born normal, and remain so until the fifth or sixth year, when they acquire the myxedematous condition. The disease is far more common among girls than boys. The genital system at puberty remains in the infantile stage. The other appearances of hypothyroidism are like those of congenital myxedema, only not as severe. Myxedema of adults is more common than the infantile type and is seen especially in certain countries. It is the result of atrophy of the thyroid gland from either a simple or inflammatory process. The disease is characterized by dryness, thickness, and coolness of the skin, which shows swellings, especially of the face, neck, and extremities. The hands look plump and short, the eye- hds hang down, and the upper hp is thick and protruding. The patient be- comes apathetic and indolent. The speech is slow and expressionless. Sweat secretion entirely ceases. The blood is reduced in red corpuscles and hemo- globin (Novak). The etiology of adult myxedema is not definitely known. Heredity seems to play a certain role, as shown by examples where it has appeared in several members of the same family. The disease is found chiefly in women, the proportion being estimated as high as 80 per cent. In a very large number of cases there are found pelvic disturbances, which, however, are probably rather the result than the cause of the disease. Severe intrapartum bleeding and too frequent childbearing have been assigned as etiologic factors. Sometimes myxedema develops during pregnancy. Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 61 The special genital symptoms that occur with myxedema are usually in the form of menstrual disturbance, either as amenorrhea or menorrhagia, for both of which conditions thyroid extract works beneficially. The disease does not always alter the genitaha, but may cause marked atrophy. Another form of hypothyroidism is seen in the condition of endemic cretin- ism, in which the disease is associated with goiter and is confined to certain localities. The etiology of this affection, usually referred to drinking-water, cannot be discussed here. Hereditary influences unquestionably play some part in its transmission. The disease manifests itself by myxedema and disturbance of genital develop- ment. As a rule, the genitals preserve the infantile type, and there is partial or complete lack of development of the secondary sexual characters, especially apparent in the breasts and pubic hair. Sometimes the genitals mature nor- mally and the individual may procreate, but is Uable to dystocia on account of narrow pelvis. THE PARATHYROIDS The influence of the parathyroids on the organism has been studied experi- mentally in animals. It has been found that in all animals where all four para- thyroids are removed death follows from acute tetany, while a partial removal of the parathyroids may or may not produce a condition of chronic tetany. The subject is of interest here in relation to the tetany of maternity, which is thought to be the result of parathyroid insufficiency. Following in line with animal experiments in which, by many investigations, successful results on tetanized animals were obtained by the implantation of parathyroid tissue, von Eisels- berg has succeeded in effecting a permanent cure of recurring tetany in a woman by transplanting a parathyroid gland from a patient who was undergoing a goiter operation. The results of parathyroid extract administration in cases of tetany have so far not been particularly encouraging. An attempt has been made to show a relationship between the parathyroids and the conditions of eclampsia and osteomalacia. Favorable results have been reported of the use of parathyroid in cases of eclampsia, but the relation- ship has not been scientifically proved and is a matter of doubt. The same may be said of osteomalacia. THE ADRENALS A functional relationship between the sex glands and the adrenals was first announced by Meckel, who observed that animals endowed with the strongest sexual powers are also possessed of markedly developed adrenals. He also found macroscopic changes in both glands in birds and amphibia during the rutting period. Meckel's observations, made over one hundred years ago, have to a certain extent been confirmed by more recent researches. Defective development of both glands is often found associated, a result, doubtless, of their original proximity in embryonal life. Negroes are distin- Digitized by Microsoft® 62 GYNECOLOGY guished by a greater development both of sex and adrenal glands than is seen in white races, a fact which confirms in the human race the observations made by Meckel on animals. Further evidence of the correlation between the two glands is the occasional appearance in the realm of the genitals of accessory adrenals consisting of adrenal, cortical, and even chromaffin tissue. One observer has demonstrated chromaffin tissue in the ovary itself. In hypoplastic individuals with under- developed sex glands a diminution of the adrenals has also been noted, though this is now thought to be not a specific result of sexual deficiency, but a part of the general hypoplastic constitution. In the condition of status thymico- lymphaticus there is also associated hypoplasia of both glandular elements. As an expression of hyperfunction of the adrenals a number of cases of female pseudohermaphroditism have been reported combined with the pres- ence of hypernephromata, and it is thought that there is a probable causal relationship between the two conditions. Hypernephromata in children produce precocious sexual development, most of the cases being in female individuals. These children show a special form of precocity, in that there is an abnormally early development of certain primary and secondary characters, such as the external genitals, pubic hair, and general bodily form without symptoms that bespeak a true function of the sexual glands, namely, menstruation or ejaculation. It is well established that castration is followed by a hypertrophy of the adrenal gland, but whether this represents a compensatory process for the loss of the ovarian secretion is not definitely known. Attention has been called in this connection to the close similarity between the corpus luteum cells and those of the suprarenal cortex. There is considerable evidence that the adrenal tissue, both that of the cortex and medulla, is hypertrophied during pregnancy and probably at menstruation, a result doubtless of increase of function. Individuals with Addison's disease frequently have a deficient genital endowment, which is regarded as a part of a general constitutional hypoplasia that predisposes to the acquisition of the disease. There are also variations in the secondary sexual characters. Addison's disease in female children, as a rule, prevents the appearance of the menses, and if it appears in adults it manifests itself by amenorrhea as one of the earliest symptoms, a matter of considerable diagnostic importance. Dysmenorrhea and menorrhagia are very rare symptoms. Individuals with Addison's disease rarely get pregnant, but if they do, abortion or premature labor are apt to occur. The effect of pregnancy on the disease is a deleterious one. Pigmentation of Addison's disease appears most markedly on the parts about the external genitals, and may be confined to this locality. Of diag- nostic interest is the fact that pelvic tumors, especially fibroids, sometimes cause pigmentation of the skin quite similar to that of Addison's disease. Digitized by Microsoft® BELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 63 PINEAL GLAND (EPIPHYSIS) Observations on the functions of the epiphysis have been made, for the most part, in individuals suffering from tumors of the gland. Conclusions made from these observations indicate that impairment of the gland by tumor forma- tion in early childhood produces a marked sexual precocity long before the age of puberty. If the gland is completely destroyed, cachexia, decubitus, etc., follow. When the disturbance of the gland produces oversecretion (hyper- pinealism) abnormal adiposity is the result. THYMUS A relationship between the genital system and the thymus has long been observed in the involution of the thymus that normally takes place at puberty. Animal experimentation has shown that castration of young animals prolongs the time of thymus involution. Other observations reveal that in individuals with hypoplastic genitals involution takes place later than normal. Status thymicus is, therefore, associated with genital deficiency. Further researches have shown that castration in the young produces no observable change in the structure of the thymus, but that castration after sexual maturity causes a definite enlargement of the parenchyma. Extirpation of the thymus has failed to prove any reciprocal functional correlation between the thymus and the genital glands. UTERUS It has been suggested that the uterus produces a toxic inner secretion, the harmful influence of which is neutralized by the presence of the ovaries. Such a theory would account for the deleterious after-effects of double oophorectomy operations where the uterus has been left in. The theory, however, has no scientific basis, there being no evidence nor probability of a uterine internal secretion. PLACENTA In the first few days of birth are noted certain appearances that have been referred to a reaction following the loss of placental secretion, and described as analogous to the involution processes of the mother. These changes in the newborn include the swelling of the breasts, from which comes a colostrum- like secretion, and in females a hyperemia and enlargement of the uterus, which in some cases may result in a discharge very like that of menstruation (see page 18). 1 It is thought that the placenta exercises a very important influence on the mother during pregnancy, and that after the primary decidual reaction and nidation of the ovum the various pregnancy changes are largely under pla- cental control. We have already seen how the corpus luteum probably prepares 1 This last phenomenon may be the result of maternal ovarian secretion exerted through the medium of the placenta. Digitized by Microsoft® 64 GYNECOLOGY and sensitizes the endometrium for nidation, and that in the first few weeks the life and growth of the ovum is, to a certain extent, dependent on the integrity of the corpus luteum. This duty, it is supposed, is then assumed by the pla- centa. That the ovaries after a certain period are of little moment in the progress of the pregnancy is shown by its uninterrupted continuance after double oophorectomy. That the involution process after labor is due to the removal of the placenta and not the fetus is evidenced by the persistence of pregnancy symptoms in cases of dead fetus and hydatidiform mole. RELATIONSHIP OF GYNECOLOGY TO THE MAMMARY GLANDS The relationship between the breasts and the genital organs is very definite, but little understood. The female breasts develop rapidly at the time of puberty. In many cases they become enlarged at the menstrual periods, while during pregnancy the hypertrophy is of a marked degree. At the menopause the breasts atrophy. In what way does the cycle of development and function of the breasts depend on the function. of the genital organs? The old theory that there exists between the mammary glands and the genital organs a specific nerve connection has been exploded as a result of more recent experiments. Galtz and Ewald were able to remove a large part of the spinal cord of a bitch without interfering with normal birth and secretion of milk in the breasts with ability to suckle the young. Similar observations have been made in women who, notwithstanding a complete fracture of the back, have been able to continue nursing their children. Pfister and Eckhardt suc- ceeded in dividing all the afferent nerves to the mammary gland in animals without disturbing the secretion of milk, while Basch reached a similar result after extirpating the celiac ganglion of the sympathetic system. The most spectacular experiment, showing that the function of the breasts is entirely independent of any nerve connection, was performed by Ribbert, who transplanted the breast of a pregnant rabbit on one of its ears. After the rabbit was delivered of its young the transplanted breast secreted milk. It has further been shown that the hypoplasia of the mammary glands which usually results from the castration of young animals may be prevented by the transplantation of ovarian tissue. From these and other experiments there seems to be no doubt that the changes in the mammary gland are due to the circulation in the blood of some chemical substance which represents a true hormone. An almost positive proof of this was demonstrated by Schauta in the case of the Siamese twins Blazek, one of whom became pregnant and bore a normal child. After the birth of the child both sisters secreted milk from their breasts. The same phenomenon has been observed by Christea in parabiotic rats and rabbits. Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 65 Although it seems to be well established that the development and func- tion of the mammary glands is presided over by some chemical hormone, the problem of the source of this secretion has not yet been solved. The amount of experimentation and speculation has been very extensive, but the results have been conflicting and unconvincing. There is little doubt that the growth of the breasts at puberty, the swelling at the menstrual periods, and the atrophy at the chmacteric are influenced chiefly by an ovarian secretion, since these phenomena do not appear after early cas- tration. The hypertrophy during pregnancy and the secretion of milk after delivery seem to be due to some other factor, since both these processes con- tinue after the removal of both ovaries during pregnancy, and, in fact, they have been shown to be dependent in some way on the suppression of the ovarian function. (The milk period is said to last longer after castration, while in normal women the return of the menses is accompanied by disturbances of the milk secretion.) The uterus has also been ruled out as a dominating agent in the functions of the breast during pregnancy and childbirth. The present line of investigation is with reference to the influence of the fetus and the placenta. The experiments along this line are of great interest, but the results are inconclusive. It may be said, however, that there is evi- dence to show that the chemical influence of the placenta plays some unex- plained part in the process, as is shown by the following experiments: Basch injected placenta extract into virgin bitches, and found that it produced no changes in the beasts. He then implanted the ovary of a pregnant bitch in the abdominal wall of a virgin animal, and produced a hypertrophy of the breast. He next injected placental extract into this animal, and produced such an intensive secretion of milk that she was able to suckle a Htter of young dogs. This experiment suggests that the complete cycle of mammary hypertrophy and milk secretion is dependent for its full expression on both the ovary and the placenta. There has been adduced no evidence to show that the mammae possess an internal secretion. Extract of mammary (mammin) has been used to some extent for the con- trol of uterine bleeding. There seems to be no doubt that the extract does exert some specific influence on the uterus, but it is not sufficiently effective to make the extract of much practical use. Aschner reports success in 16 out of 23 cases treated for functional menorrhagia and menorrhagia due to adnexal disease, fibroids, and uterine insufficiency. RELATIONSHIP OF GYNECOLOGY TO THE SKIN^ There is an important connection between certain skin lesions and the physiologic and pathologic processes of the genital organs. The changes in the skin are seen most markedly in those periods during which the genital organs 1 Principal authorities, Troph, Walthard, McCarthy. 5 Digitized by Microsoft® 66 GYNECOLOGY undergo special activity, namely, the age of puberty, menstruation, pregnancy, the puerperium, and the menopause. (The skin manifestations accompanying pregnancy and the puerperium, though important, will be necessarily omitted in the following discussion.) Certain pelvic diseases are also associated with skin changes, while the external genitalia are subject to well-defined dermatologic affections. Menstrual Changes in the Skin. — Menstruation is preceded for several days by an increased hyperemia that is most apparent in the skin of the cheeks, the chest, and thighs. This can be seen best in individuals who are naturally pale. The hyperemia recedes during the period and is succeeded for a few days by an unusual pallor. In individuals with high color the menstrual hyperemia is less apparent, but can be recognized by observing the changes in those parts which are normally pale — around the eyes, mouth, and chin. There are numerous skin eruptions related to the catamenial period which are classified under the term "menstrual exanthemata." The cause of these changes is not definitely known; some refer it to the influence of the ovarian secretion circulating through the system; others see a reflex or trophic disturb- ance in the innervation of the skin. The clinical picture of menstrual exanthemata is extremely varied. They may be discreet or diffuse, localized or general, urticarial, vesicular, macular, papular, resembling closely the appearance of er3^hema exudativum multiforme, or even of erjrthema nodosum. The location of the eruptions is usually on the thighs, abdomen, and breasts, but they may occur on other parts of the body. They make their appearance several days before the onset of the period, and either disappear at the cessation of the flow or last for several days after. Occasionally they break out only in the intermenstrual periods. The commonest form of these eruptions is the so-called herpes sexualis or menstruation herpes. This appears chiefly about the lips and nostrils, sometimes around the ears or eyes, occasionally on the breasts, fingers, and palms of the hands. It may also affect the mucous membrane of the mouth or the vagina and vulva, and has been described as involving the cornea of the eye. Menstrual herpes may be accompanied by other exanthemata and even by bleeding of the skin. PoUand describes a well-defined eruption that he terms dermatosis dysmenorrhoica sym- metrica. This is a disease which appears only in women who suffer from menstrual disturb- ances, chiefly dysmenorrhea. The eruption begins with hyperemia of the perifolliciilar vessels, followed by serous or bloody exudation and the formation of vesicles on the epidermis. Ordi- narily the process extends over only a few days, but in some cases there is necrosis and iilcera- tion, eventuating in a scar. The eruption may be almost universal over the body, but it is always symmetric. It often appears at puberty. Polland finds that the disease is benefited by ovarian extract (ovaraden triferrin) and beUeves that it is due to a disturbance of thejnternal secretion of the ovary. Digitized by Microsoft® RELATIONSHIP OP GYNECOLOGY TO THE GENERAL ORGANISM 67 I Genital herpes is seen frequently in prostitutes and in individuals with great sexual irritability. Its occurrence is, however, usually closely related to the naenstrual function. A purpuric type of erythema is sometimes seen in the form of ecchymoses or petechise which appear several days before menstrua- tion, and are often swollen and painful. Another form of hemorrhagic skin lesion is that due to vicarious menstrua- tion which may take place from the intact skin, from various mucous mem- branes, and from scars, wounds, and ulcers. Acute edema is sometimes seen associated with menstruation and the climac- teric, the edema occurring chiefly about the eyes, in the lower extremities, or in the external genitals. Pemphigus may occur in young girls in whom menstrua- tion has not been regularly established or who suffer from dysmenorrhea. Eczema is sometimes seen with various pelvic diseases, and it is thought by some that there may be a neurotic relationship between the two affections. Eczema at the time after the menopause, usually appearing on the scalp and behind the ears, occurs sufficiently often to be regarded as a specific disease under the term "climacteric eczema." Eczema of the external genitals and surrounding parts is very frequently seen in connection with pruritus and various pelvic diseases which produce an irritating discharge. In this case the eczema is the result of chemical changes in the skin wrought by the contact of the harmful secretions. Acne is a very common manifestation at puberty, though less frequent in girls than in boys. In matured women who are affected with acne there is usually a distinct relationship between menstruation and the appearance of the pustules. Acne of this type is locahzed chiefly about the chin. Individuals suffering from various pelvic disturbances, especially those that lead to scanty and irregular menses or to leukorrhea, seem to have a pre- disposition to acne. Women at the climacteric also frequently suffer from acne eruptions. Furunculosis of the external genitalia is sometimes seen as a chronic disease, and may be a source of great distress to the patient. The chronic or constantly recurring type is apparently a manifestation of deficiency in the function of the ovaries, by which the local resistance of the external genitals is lowered toward pyogenic organisms. That this theory is probably correct is shown by the curative effect of treatment with ovarian extract. A certain relationship between erysipelas and the menstrual function has been estabhshed, cases having been cited in which there have been periodic attacks of erysipelas coincident with the menses. There is a very close and well-known relationship between pigment hyper- trophy and the functions of the pelvic organs. At the time of puberty there is a physiologic increase of pigment, seen especially in the skin of the external genitals, about the nipples, and along the linea alba. During pregnancy the Digitized by Microsoft® 68 GYNECOLOGY pigment of these areas is markedly hypertrophied, while irregular spots of brown pigmentation appear on the iace (chloasma gravidarum). Increase of pigmentation is often seen in individuals suffering from menstrual disturbances, chiefly amenorrhea and dysmenorrhea. With pelvic tumors, especially the large ovarian cysts, there is. often a noticeable increase of pigmentation. Vitiligo is not infrequently seen in association with abdominal tumors, and is thought to be the result of some toxic influence issuing from the tumor. This seems a reasonable theory, as the removal of the tumor often causes a marked improvement in the appearance of the skin lesion. Postoperative Eruptions. — One of the commonest skin affections encoun- tered in gynecologic practice is the postoperative eruption popularly known by the somewhat misleading designation of "ether rash." This does not refer to the temporary erythema frequently seen during the administration of ether, which usually disappears by the time the patient recovers consciousness, but represents a well-defined disease that appears from a few hours to several days after the operation and runs a short but characteristic course. Observations of this disease are scanty and the etiology obscure. McCarthy, who has most recently studied the affection, found that in a series, of 1000 consecutive opera- tive cases at the Free Hospital for Women postoperative eruptions occurred 43 times. He divides the cases into two types, those which appear within twenty-four to forty-eight hours after the operation, and those with a later onset, the latter following a more definite course. He describes the cases "with early onset as exhibiting an eruption on the upper half of the body, beginning either on the face, chest, or arms and rapidly involving the abdomen and legs. The face is affected in almost every instance. The eruption varies in charac- ter from an erythema of brief duration to a papular type lasting for several days- Itching is the most marked symptom. There is little systemic disturbance beyond a mild elevation of temperature. In the second class of cases, which have a later onset of three to seven days after operation, the appearance -of the eruption is sudden without prodromata, excepting that the temperature chart has usually continued higher than is seen in the ordinary uncomplicated post- operative convalescence. The condition varies in severity, from that in which only a localized part of the body is affected to one in which almost the entire body surface is involved. The eruption begins as a fine papular efflorescence on the inner surfaces of the forearms and thighs and extending over the body, rarely including the face and never the palms and soles. There is intense troublesome itching, which persists untU the eruption has disappeared. The papules are at first pink, but may later assume a dark reddish hue. The course of the disease reaches its height in twenty-four to thirty-six hours, and then rather rapidly subsides, the average duration being four days. McCarthy notes that those cases which begin on the third or fourth day after operation are of the longest duration and of greatest severity. The temperature remains slightly elevated, with httle change in the pulse. There is also a moderate leuko- Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL. ORGANISM 69 cytosis which is almost constant, and shown by control observations to be greater and more persistent than that frequently seen in uncompHcated con- valescence after- surgical operation. Numerous etiologic factors have been suggested to. account for postopera- tive eruptions, the disturbance being referred to the effect of ether, calomel, magnesium sulphate, morphin, and various substances used in enemata. Some have attributed the rash to chemicals used in laundering hospital linen. Some have ascribed it to climatic conditions. Others regard the disturbance as a manifestation of mild undetected sepsis, or to the absorption of tissue destruction at the site of the wound. McCarthy has analyzed all the causes usually given, and finds that no one of them is applicable to all cases. He concludes that the affection represents a vasomotor disturbance which may be evoked from the sympathetic nervous system by a variety of exciting causes. On this theory he accounts for the greater frequency of these eruptions in women, whose nervous organism is more easily disturbed than in men. The theory also explains the greater frequency of the eruptions in a gynecologic clinic than in one devoted to general surgery, in view of the rich supply of sympathetic nerves with which the female pelvic organs are endowed. RELATIONSHIP OF GYNECOLOGY TO THE ORGANS OF SENSE There exists between the organs of sense and the genitalia a relationship of considerable definiteness, the most marked manifestations being connected with the function of menstruation. The eye may undergo various functional and pathologic changes as a result of genital influences. Vicarious menstruation following suppression of the normal function may appear in the eyes, with extravasations of blood in the conjunctiva, eye muscles, lens, choroid, retina, or even in the optic nerve. The corresponding disturbances of vision disappear with the absorption of the extravasated blood if it is small in amount. If, however, the bleeding has been profuse the condition may be followed by chronic inflammatory or degenerative processes. Even in the presence of normal menstruation from the genitaha, hemorrhages may take place in various parts of the eye and cause more or less serious disturbance. Other pathologic processes sometimes seen in the eye induced by the in- fluence of menstruation are eczematous changes in the lids, herpes, hordeola, inflammations of the conjunctiva and cornea, or the aggravation of already existing inflammatory conditions. Increase of the pressure in the eye may occur, even to the extent of glaucoma. Even with normal menstruation numerous functional disturbances may take place, such as a narrowing of the field of vision, dulness of vision, weakness of accommodation, photophobia, oculomotor paralysis, lessening of color sense, etc., disturbances which may be much more marked if the menses are ab- Digitized by Microsoft® 70 GYNECOLOGY normal. Such functional aberrations may sometimes be regarded as mani- festations of psychoneuroses in nervous individuals during a period when the organism is pecuharly sensitive. Secondary anemia from severe Iobs of blood from the genitals may be fol- lowed by anomalies in the eye, chiefly in the form of edema and thrombosis, which may produce permanent degenerative processes in the retina and optic nerve. In this way bleeding tumors may affect the eye. Malignant growths of the pelvis sometimes metastasize in the eye. Infectious diseases of the pelvic organs may affect the eye either by direct contact with the infectious material or by embohc processes through the cir- culation. Of the former method, infection from gonorrheal discharges is the most familiar example. Diphtheria may also be transmitted in the same way. Metastatic infection of the eye is extremely rare excepting in connection with puerperal fever, in which it occasionally, though rarely, occurs. The embohc focus may have its seat in almost any part of the eye, but most commonly in the retina, whence it may extend to a general panophthalmia. Puerperal sepsis sometimes causes a hemorrhage in the eye a"s a result of toxic changes in the blood composition and a greater permeability of the endo- thelial walls of the capiUaries (Mayer) . The Ear. — What has been said regarding functional disturbance of the eye during menstruation is also applicable to the ear, i. e., certain aberrations .from the normal cases may be referred to the general influence on the organism of the menstrual wave, and in others to manifestations of psychoneurotic impulses which become more active during the monthly period of greater sensitiveness. Existing chronic diseases of the ear have been observed to become per- manently aggravated by pregnancy and childbirth. The Nose! — Between the nose and the genital organs there exists a curious interrelationship which in some cases is quite inexplicable. The .sense of smell is one of the most powerful sexual -excitants. Marked changes in the nose are often seen during the menstrual period. Vicarious menstruation is more often manifested by bleeding from the nose than from any other part of the body. Individuals who menstruate normally are often prone to epistaxis dur- ing the period. During the time of puberty nose-bleeds are very common. Anomalies of secretion are often seen at the time of catamenia, and may consist either of acute nasal catarrh with profuse secretion or of abnormal dryness of the nasal mucous membrane. Disturbances in the sense of smell are some- times observed during menstruation, evinced usually by an increase of sensitive- ness or by perversions. Nasal affections during the catamenial period are much more common in those whose menstrual function is not normal, appearing with especial fre- quency in women who suffer from dysmenorrhea. They are also more frequent in neurotic individuals. What was said, therefore, regarding the functional disturbances of the eye and ear applies also to the nose. Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 71 Cohabitation is sometimes attended with acute swelling and discharge from the nasal mucous membrane; sometimes with unnatural dryness of the nose and throat. Kermauner has observed am abnormal lack of nasal secretion in those who habitually masturbate, and in the young who are addicted to this habit he recog- nizes a characteristic expression caused by a thickening and coarsening of the nose and Ups similar to that produced by certain diseases of the hypophysis. The most striking example of the relationship between the nose and the genital organs is the influence on dysmenorrhea that can sometimes be ex- erted by cocainizing the nasal mucous membrane. A few drops of 20 per cent, cooain solution apphed to the anterior end of the lower turbinate and the tuberculum septi (genital spot) will often, according to the best authorities, cure severe dysmenorrhea and prevent its recurrence for a considerable period of time (Fleisch, Brettauer, Meyer). Finally, at the time of the cUmacteric one sometimes sees a severe intractabje nasal catarrh associated with hyperesthesia of the fifth nerve. Other abnor- malitie's mentioned by Kermauner, as occurring at the change of life, are dry- ness and stoppage of the nose, adenoid and polypoid growths, and eczema ex- tending from the outer skin of the nostrils to the mucous membrane hning. liELATIONSHIP OF GYNECOLOGY TO THE DIGESTIVE TRACT The relationship existing between the genital organs and the digestive tract is evident chiefly at the time of menstruation. Increased activity of the parotid glands has been repeatedly observed, so that in some cases one may speak of the condition as menstrual salivation. This phenomenon was noticed by the earlier writers, one of whom described a "vicarious salivation," which he said might take the place of the normal uterine flow. Habran described a case of periodic swelling of the parotid gland which ceased during the months of preg- nancy, to be resumed again after delivery of the child. Disturbances of the mouth during menstruation have been cited, such as herpes of the lips, periodic toothache, and the vicarious bleeding from the gums. Of especial importance is the relationship between menstruation and dis- turbances of the stomach, evidence of which is seen both in functional dis- turbances and in connection with organic disease. The functional symptoms appear usually in the premenstrual stage and last into the menstrual period, though sometimes they cease with the onset of the bleeding. The most common symptoms of a subjective character are loss of appetite, flatulency, nausea, vomiting, taste paresthesias, aversion to certain foods, especially meat, bad breath, pains in the stomach, sensations of hunger, etc. Symptoms of this kind are much more common in the neurotic and in those who suffer from abnormalities of menstruation, especially dysmenorrhea. Digitized by Microsoft® 72 GYNECOLOGY Besides these minor anomalies of the stomach, more serious disturbances may occur. Menstrual and vicarious bleeding from the gastric mucous mem- brane may occur, and may on some occasions constitute alarming and depleting hemorrhages. In some cases there may be severe cardialgia and symptoms simulating gastric ulcer, the differential diagnosis being very difficult. In a case of this kind seen by the author the patient had five abdominal scars, repre- senting as many operations performed, with the diagnosis of some serious intestinal lesion. The influence of menstruation is definitely shown in the aggravation of organic lesions of the stomach during the monthly period. This effect is especi- ally seen in ulcer of the stomach, which has a special disposition to bleed during the premenstrual and menstrual periods. Thus, it may be impossible to state whether monthly bleeding from the stomach is vicarious menstruation without actual stomach lesion, or whether the bleeding is from an ulcer which bleeds only when influenced by menstruation. The cause of the influence of menstruation on the functions and conditions of the digestive tract is as little known in this connection as it is in relation to other parts of the body. Wagner sums up a discussion of the matter by say- ing, "Whatever the cause of the disturbances may be, two facts are indubitably established : first, the secretory and motor activity of the stomach undergoes a premenstrual and menstrual alteration; and, secondly, that this leads to symp- toms according to the special disposition of the individual." Subjective gastric symptoms are not seen in all women at the time of menstruation, but they appear in a considerable percentage of them. Those specially disposed to the condition are the neurasthenic and hysteric. Some regard the dyspeptic symp- toms of these patients as purely nervous reflexes, while those who accept the internal secretion theory regard neurotic patients as peculiarly susceptible to the influences of altered secretion at the menstrual period. If the condition is due to secretory changes the nature of the process is not understood. Accord- ing to some, it is the direct result of an ovarian hormone circulating in the body. It would seem somewhat more reasonable and in accordance with present physiologic knowledge to suppose that the stomach changes are rather due to a disturbance of balance in the relationship of the glands of internal secretion during menstruation, and that the direct influence exerted either on the nerves of the stomach or on the stomach tissues themselves comes from some other gland than the ovary, probably the adrenals. Or, still further, it might be assumed that the gastric symptoms of menstruation may be the result of in- creased general nervous and emotional irritability, and that this condition produces hyperactivity of the adrenal glands with consequent influences on the secretory and motor apparatus of the stomach. This theory is in line with the well-known experiments of Cannon, who has demonstrated the effect of the emotions on the processes of digestion through stimulation of the adrenal glands. Digitized by Microsoft® RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 73 In addition to the neurasthenic and hysteric, a predisposition to menstrual gastric disturbances is seen in the chlorotic and anemic, and still more com- monly in those who suffer from congenital or acquired malpositions of the stomach. In the latter class of cases belong chiefly individuals of the hypo- plastic type, with the long narrow chest walls, splanchnoptosis, pelvic mis- placements, etc. Patients with organic lesions of the stomach undergo exacerbations of their symptoms during the menstrual period in 83 per cent, of cases, according to Plonies. A form of menstrual bleeding from the intestinal tract is that sometimes seen in patients suffering from typhoid fever. Still another instance, and one quite frequently seen, is the increased tendency of hemorrhoids to bleed at the time of menstruation. Diarrhea is not infrequently an attendant discomfort of menstruation, one observer having found it in 49 per cent, of cases in a study of 758 women, though this figure seems rather high. Obstipation is another not uncommon symptom. StiU another class of patients frequently seen suffer from chronic constipation between the periods, while during menstruation the bowels are regular or even diarrheic. Certain digestive disturbances often characterize the menopause, such as pains in the pharynx and esophagus, nervous dyspepsia with flatulence, heart- burn, vomiting, etc. (Wagner). Diarrhea of a peculiarly obstinate nature sometimes signalizes the begin- ning of the change of life (Singer), and has the character of a secretion neurosis, without sign of catarrhal, or inflammatory disease (Wagner). Somewhat more common is the occurrence at the chmacteric of intractable obstipation, with great tendency to gas formation. Wagner states that the constipation of the climacteric is peculiarly resistant to the usual methods of treatment. In two cases he has had good results with ovarian therapy. Hemorrhages from the bowels are sometimes seen at the change of hfe. Most of the bleedings are from hemorrhoids, which at that time have a special tendency to become worse. In other cases where malignant disease has been excluded there has been demonstrated a true climacteric intestinal bleeding from the mucous membrane. It is possible that this may be analogous to the bleeding frequently seen from the vaginal mucous membrane as a result of senile atrophy. The relationship between the genital system and the neighboring organs of the digestive tract is treated in another section. (See page 101.) The connection between pregnancy and the organs of digestion is a subject of much importance, but does not come within the sphere of this book. The subjects of enteroptosis, intestinal bands, and diverticulitis are treated elsewhere. Digitized by Microsoft® 74 GYNECOLOGY RELATIONSHIP O'F GYNECOLOGY TO ORGANS OF RESPIRATION Lung complications following gynecologic operations are comparatively frequent. Pulmonary embolism is discussed in the section on the Relationship of Gynecology to the Circulatory Apparatus. The subject of postoperative infections of the lungs forms a very important chapter in surgical convalescence. These infections most commonly take the form of pleurisy, bronchitis, and bronchopneumonia. Typic lobar pneumonia is rare. As in other local infections following operation, such as phlebitis and pyeli- tis, etc., the causation of pulmonary inflammations is not well understood, many reasons having been suggested. Patients who develop pneumonia soon after a surgical operation are commonly said to be suffering from "ether pneumonia." It is probable, as we shall see, that ether may in some cases be an exciting factor; nevertheless, that it is not the sole cause, is shown by the fact that in- fections of the lungs may follow operations performed under spinal anesthesia or after the gas and oxygen sequence. There are many predisposing conditions which undoubtedly have some in- fluence in producing the disease. Thus, surgical shock may so lower the patient's resistance as to encourage a local inflammatory process. Old age is very distinctly favorable for lung infections. In our own series of cases the incidence of serious pneumonia was particularly noticeable in elderly women. The physical characteristics of the patient are supposed to have some influence, fat, short-necked individuals being thought to be es- pecially prone to pulmonary complications. In our series this theory has not been borne out. Bad behavior under ether — i. e., choking, vomiting, straining, etc. — plays a certain role, as it is probable that such patients sometimes inhale mucus, sahva, or particles of food that may later act as foci for infection. It is probable, too, that when patients act badly under ether the necessity of forcing the