Diseases of the Female Sex Organs

The female sex organs include the breasts, the ovaries, the oviducts, the uterus, the vagina, and the vulva. Their fundamental function is to help pro­duce a new human being and nourish it until it can take other food than milk. In the production of such a new human being, no substitute has been found for either the ovaries or the uterus, but the breasts all too often fail to do their duty or are discharged from the job whether they should be or not.

Breast Diseases
ACUTE MASTITIS (INFLAMMA­TION OF THE BREAST).
The most common acute disorder of the breast is acute inflammation. It nearly always occurs during the early stages of the nursing period. Cracks or small injuries of the nipples usually precede the inflammation and prepare the way for the entrance of the disease germs which cause the trouble.

The inflammation occasionally affects only the nipples and the surrounding skin. In such cases careful cleansing of the nipples, with frequent applications of a saturated solution of boric acid, is all that is necessary. Boric acid solution, however, should not be applied to the nipples while the baby is being breast fed, unless thoroughly rinsed off with cooled boiled water after being ap­plied.

When it is only the nipple or the nipple area that is affected, the use of a nipple shield at the time of nursing is often helpful. Should tiny fissures (cracks) develop in the nipple, they can be painted with tincture of ben­zoin, which is readily available at the drugstore.

The inflammation is often more ex­tensive, however, than described above, affecting deeper parts of the breast; and then it may not respond to simple treatment. It should be noted here that while we have been speaking of the breasts in the plural, an acute inflammation much more of­ten affects only one breast rather than both of them.

The first signs and symptoms noticed when an infection begins to affect the deeper tissues of the breast are tender­ness, pain, and swelling. There may be a chill, and the fever may be moderate or high, depending on the severity of the infection. In comparatively severe cases there will be a rapid pulse, with headache and other characteristic symptoms that usually accompany in­fection and fever.


What to Do
1. When the first signs and symp­toms of breast inflammation appear, consult a physician at once. The use of penicillin or some other antibiotic will usually prevent the formation of an abscess.
2. Take the baby off the breast, so the breast can be at rest.
3. There should be bed rest, but with toilet privileges.
4. Support the inflamed breast with a well-fitting brassiere or binder, which, however, should not be too tight.
5. The patient should be allowed to drink water freely, and as long as the fever lasts the diet should con­sist of soft and liquid foods only.
6. Cover the inflamed breast with a dry towel and lay an ice bag over the towel, keeping it in place for about two hours. The procedure should be repeated every three hours.
7. Do not try to pump milk out of the breast unless it becomes pain­fully engorged. If a physician is su­pervising the case, which will prob­ably be true, he should give orders about the use of a breast pump.
8. If an abscess forms, the physi­cian will take care of such surgical drainage as may be needed.

CANCER OF THE BREAST.
CHRONIC CYSTIC MASTITIS.
About the time of the menopause, or even before, somewhat tender and quite freely movable lumps are likely to develop in one or both breasts. These lumps may be harmless cysts or early cancer.

What to Do
1. Have the lump or lumps ex­amined by a physician as soon as possible. The only reliable way to detect or exclude cancer is to have a sample of the lump tissue removed and studied under a microscope.
2. If cancer is found, arrange for surgery as soon as possible, since breast cancer begins to spread fairly early.

Miscellaneous Diseases of the Female Sex Organs
FEMALE GENITAL FISTULAS. Accidents, infections, abscesses, ma­lignancies, or tissue damage such as occurs infrequently at childbirth, may result in perforations or lacerations of various parts of the female genital tract; and fistulas of various sorts may be formed. There may be openings between the bladder and the uterus or the vagina, or between the urethra and the vagina, resulting in a dribbling of urine from the vaginal outlet. There may be an opening between the rec­tum and the vagina, with fecal mate­rial seeping into and out of the vagina. Other fistuals are rare.

What to Do
Arrange for surgical repair.
LEUKORRHEA.
Leukorrhea is not a disease, but it may be a symptom of some disease of the vagina, cervix, body of the uterus, oviducts, or some of the glands associ­ated with the genital tract. It is a trou­blesome discharge of fluid containing pus or mucus or both.

The discharge is usually white or whitish in color, which fact explains the word "leukorrhea." This word literally means "something white running or flowing down." Such a discharge is commonly present in chronic infections of the cervix, in gonorrhea, and in a host of other con­ditions, each of which may require its own specific treatment after careful study of its true nature by a physician.

A common and persistent form of leukorrhea results from an infection by a parasite called Trichomonas vagi­nalis. This infection affects the cervix and the membrane lining the vagina. It causes not only a discharge but a chronic inflammation with more or less itching and burning. Another parasitic infection which often causes intense itching and burning of the cervix and vaginal lining is that of Candida albi­cans, which produces a thick, white, cheesy vaginal discharge.

What to Do
Learn the cause of the discharge. It cannot be checked safely and per­manently unless the cause is removed or corrected. Both detection and removal or correction usually re­quire the aid of a physician. For each of the several causes of leukorrhea there is a specific treatment. It is especially important not to delay consulting a physician if the dis­charge between periods is at all blood-tinged.

PERINEAL LACERATIONS.
Some injury to the mother's pelvic outlet is unavoidable in childbirth. The tissues are more or less bruised, stretched, and torn. But with good ob­stetrical care the amount of laceration is usually so slight that it can be suc­cessfully repaired by a few stitches taken immediately after the delivery of the child. In spite of the best of care, however, bad lacerations, involv­ing a large part of the pelvic floor, sometimes occur.

The severity of the tear may not be apparent until a thor­ough examination is made a few weeks after delivery.
Unrepaired perineal lacerations may cause a feeling of heaviness in the pel­vis, a sense of loss of support to the pelvic organs, pain in the ovaries, head­ache, general lassitude, physical de­bility, and nervousness. Constipation is common.

The uterus is invariably in an abnormal position, pulling on some of the organs surrounding it and press­ing on others. It may have sagged down to such an extent that the cervix protrudes from the vagina. Straining at stool causes the rectum to pouch into the vagina, producing what is called rectocele. Lack of proper sup­port allows the bladder to pouch in on the front of the vagina, producing cys­tocele. This interferes with the proper emptying of the bladder, and cystitis may result. All these conditions taken together and many of them may exist at the same time result in a vast amount of discomfort and ill health.

What to Do
If there are symptoms indicating persistent results from cervical lacer­ations, have a physician, preferably a gynecologist, make a careful ex­amination. Have a perineal repair operation performed if he so recom­mends. Surgical repair may mean the difference between chronic semi-in­validism and good health.

STERILITY (INFERTILITY).
The inability of a woman to become pregnant may be due to underdevelop­ment of some of the sex organs, for which there is usually no cure, though hormone injections may help in some cases.

It may also be caused by con­stitutional conditions, or by physical overwork, nervous tension, endocrine disorders (especially ovarian), infec­tions, tumors, cervical erosions, or ob­structions or strictures of the oviducts. Before surgery or any other extensive procedures are undertaken on behalf of the wife, consultation should be sought regarding sex habits, and the husband's genital organs and semen should be examined.

What to Do
1. Consult a physician, preferably a gynecologist, to study the cause of the trouble. He may be able to de­tect it, and in some cases to cor­rect it.
2. Before going ahead with ex­tensive corrective measures of the wife's condition, have the husband examined.

URETHRITIS (INFLAMMATION OF THE URETHRA).
Inflammation of the urethra is com­monly caused by a venereal infection. It can also be caused by other types of infection. In still other cases, no infec­tious agent can be demonstrated (non­specific urethritis).

URETHRAL CARUNCLE.
Urethral caruncles are small tumors protruding from the urethral opening. They may be angiomas (blood-vessel tumors), small masses of granulation tissue growing from the membrane lining the urethra, or polyps. They are usually exceedingly sensitive and pro­duce extreme pain on urination. A few of them become malignant.

What to Do
Do not attempt any home treat­ment. Consult a physician, prefer­ably a urologist or a gynecologist, since surgery is the only effective remedy.
Ovarian Disorders

MENOPAUSE.
It is hardly proper to call the meno­pause a disease, because it comes natu­rally to every normal woman who lives out an average lifetime. But it is so of­ten accompanied by various distressing symptoms that it is discussed here among the diseases of women's sex organs.

There is some logic, however, in con­sidering it as an ovarian disorder. Men­struation begins as a result of the ma­turing of the ovaries, and it ends when their normal function ceases. The ac­tion of ovarian hormones has much to do with the changes in the lining of the uterus which produce the men­strual flow, and the use of ovarian hor­mones is often a useful remedy for the unpleasant symptoms of the meno­pause.

Menstrual periods normally come about once a month from puberty to the menopause, except during preg­nancy or lactation. As the menopause, or change of life, approaches, there is often an irregularity of the flow-a missing of a period, or too frequent or too profuse flows. The menopause usu­ally comes at about age forty-eight, but it may occur several years earlier or somewhat later.

At this time the pelvic organs begin to shrink in size, and the sex organs lose their reproductive power. As the menopause approaches, women often have hot flashes followed by chilliness. Some of them fail in general health, lose weight, and have a poor or capri­cious appetite. There may be reflex nervous symptoms nausea, vomiting, and disturbances of the action of the heart or other organs. There may also be extreme weakness, depression, and even melancholia. All the symptoms that commonly plague women seem to crowd in during the menopause head­ache, backache, digestive disturbances, fainting, constipation, diarrhea, sore­ness of the breasts, nervousness, et cetera.

The duration of the menopause var­ies greatly in different women. Some cease menstruating abruptly with no disturbing symptoms at all. On the average, the nervous and irregular menstrual symptoms last from a few months to a year or two. With some women the discomfort and nervous symptoms may persist for many years.

The menopause is a critical time in the life of a woman; and, before she reaches it, care should be taken to avoid disturbing influences as far as possible and to put the body into as good a condition of general health as can be attained. Much of the suffer­ing that accompanies the change of life could be avoided by careful treatment of menstrual disorders before this time comes and by maintenance of good general health, both physical and men­tal.

What to Do
1. Light work, outdoor exercise, plenty of sleep, a wholesome diet, and tonic treatments such as daily cold mitten frictions could usually improve the general health and make the menopausal symptoms less severe.
2. Hormones taken under the di­rection of a physician are often helpful in relieving the headache, nervousness; and hot flashes charac­teristic of the menopause in many women. The physician may give the hormones by injection or prescribe them to be taken by mouth.

OVARIAN TUMORS.
Some tumors of the ovaries come as a result of abnormal developments in connection with the normal function of the ovaries. The ovaries normally pro­duce the ova, or egg cells, any one of which, when fertilized by union with a male sperm, can develop into a child. Each of these ova lies in a separate sac in the ovary, and at a certain time in relation to each menstrual period one of them should normally escape when the sac containing it bursts. The little sacs (follicles) containing the ova sometimes fail to burst, however, and gradually become distended with fluid, forming troublesome ovarian cysts.

Cysts of other origin may also form in an ovary. Some of them can reach an immense size if not discovered and removed in time. These very large ovarian cysts, however, are rarely seen in places where the services of modern surgeons are available because they are discovered and removed before they reach such a large size. Cases are on record in the experience of mission­ary doctors where a woman weighed scarcely half as much after the removal of such an ovarian cyst as she did be­fore it was removed.

One type of ovarian cyst is called a dermoid. This type is peculiar in that various body structures, such as bones, teeth, or hair, are found in the cysts. Solid tumors of the ovary also occur. Any tumor of the ovary may, as it becomes larger, produce pain and abdominal distention. All ovarian tumors that do not subside spontaneously within a short time should be surgi­cally removed, as harmful or danger­ous complications may occur if they are allowed to remain and grow.

Some ovarian tumors are cancerous, or may become so, though the great majority are nonmalignant. The pos­sibility of cancer, however, is another reason to have them removed.

What to Do
1. As soon as the presence of an ovarian tumor is suspected, consult a physician, preferably a gynecologist, and have him examine the condition to find out whether or not such a tu­mor is present.
2. If a tumor is found, arrange to have it surgically removed.
ECTOPIC PREGNANCY (TUBAL PREGNANCY).

ABSENCE OF MENSTRUATION (AMENORRHEA).
Amenorrhea is a condition in which the menstrual flow fails to appear for one or more months during the time between puberty and the menopause. That which occurs during pregnancy or lactation is normal, of course, and needs no treatment. Fundamentally, amenorrhea may not indicate a disease of the uterus at all, the fault being else­where; but the uterus is the organ in which its manifestations appear.

It is a symptom, and not a disease. The condition occurs fairly often dur­ing the first few years after puberty. When it occurs in girls past the age of fifteen, it is most often because of over­work, excessive study, some infectious disease, heart disease, or merely emo­tional tension. As some women put on weight, they have a diminished flow; or the flow may entirely cease. This does not preclude pregnancy, though it makes it less likely.

Amenorrhea may be due to an ob­struction in the cervical canal or to some malformation of the female or­gans. In rare cases the uterus remains in an infantile state; and, though hor­mone injections may help, as a rule no treatment does any good. Most cases of cervical obstruction and some cases of organ malformation can be cor­rected by surgery; but a cure, of amen­orrhea in the majority of cases must come from removal, correction, or treatment of the underlying cause by other than surgical methods.

What to Do
1. Give attention to the afflicted person's program of work or study, and to her general health habits. The way to cure her amenorrhea may thus become obvious. To change her work or study program may be difficult, but amenorrhea from these causes is not of itself a cause for alarm.
2. If the girl or woman is in run­down condition, correct the health habits. She should take an adequate amount of nourishing food. She should take at least an hour of mod­erate physical exercise in the open air every day. A cold mitten friction should be taken every day, except the days when the menstrual flow is due (or in progress). Alternate hot and cold applications every week would be helpful. She should get at least nine hours of sleep a night.
3. If the cause of the amenorrhea is not obvious, or if it is something that home treatments cannot cope with, consult a physician. Some causes of amenorrhea cannot be de­tected without study by a physician, and some of the most effective treatments for it must be professionally administered.

CANCER OF THE UTERUS.
CERVICAL LACERATIONS.
Childbirth is always attended by some injury to the cervix (the outlet of the uterus) . Small lacerations usually heal without trouble. Extensive lacera­tions, however, may cause much dis­comfort and ill health. Chronic inflam­mation of the membrane lining the uterus and a disagreeable discharge from the vagina are common compli­cations of neglected cervical lacera­tions. Old, unrepaired, eroded lacera­tions predispose to cancer, a common and most serious disease of the cervix.

About six weeks after childbirth, ev­ery mother should return to her physi­cian for a pelvic examination, at which time, if needed, treatment may be given to the cervix to prevent the de­velopment of possible chronic trouble. If this were done following every de­livery of a child, and if the examination were repeated annually thereafter, most cases of cervical cancer could be prevented or detected at an early cur­able stage. Much suffering would thus be avoided and many lives saved.

What to Do
Follow the pelvic examination program outlined above, and have any abnormal conditions repaired without delay.

DISPLACEMENTS OF THE UTERUS.
The uterus is held in position by four pairs of ligaments, by the muscles and fascia below, and by the fat found in the tissues of the pelvis. The organ may be displaced backward, sideways, or downward.

Tumors of the uterus may drag or push it into various abnormal posi­tions. Tumors located in any of the surrounding structures may displace it by pressure. Lastly, imperfect devel­opment of the supporting structures of the organ may result in displacement.
There are only two types of uterine displacement that may cause trouble. One is retroversion, or a backward tipping of the organ. This backward tipping may be accompanied by a sag­ging downward also. The most com­mon position of the body of the uterus is forward and upward.

The other type of displacement is prolapse, or a settling downward of the organ, which is sometimes so extreme that the cervix , protrudes from the vulva, and may drag down with it a part of the bladder and of the rectum. This condition is more common after the change of life than before. Loss of weight, weakening of the ligaments, and unrepaired lacerations are the chief causes of this downward sagging.

A displacement may be responsible for a woman's being unable to become pregnant; and, if she does conceive, abortion may result. With the back­ward position, the supporting liga­ments may be stretched, causing congestion of the oviducts, ovaries, and uterus as they are pulled back into the hollow of the sacrum against the rectum. Other results are backache low over the sacrum, constipation, and menstrual pain. Most retroversions, however, are symptomless.

What to Do

1. If there is discomfort, and if displacement of the uterus is sus­pected, have a physician, preferably a gynecologist, make an examination to determine the true condition. If he finds the condition sufficiently se­rious, he may advise the insertion of tampons or pessaries into the vagina to help support the uterus. He may recommend surgery.
2. If it is not necessary to have surgery or to use tampons or pessa­ries, and if the displacement is backward, as is usually the case, the following measures are recom­mended:
A. Avoid heavy lifting as far as possible, and do not stand any more than necessary while at work.
B. Build up the general health by taking moderate exercise, plenty of rest, a balanced diet, and hot half baths.
C. If the displacement is due to a heavy uterus which has failed to re­turn to its normal size after child­birth, a cold rubbing bath every day except during the menstrual period may help.

DYSMENORRHEA (PAINFUL OR DIFFICULT MENSTRUATION).
There are two forms of dysmenor­rhea: the primary or congenital form in which no abnormality can be found in the pelvic organs, and the secondary or acquired form in which an examina­tion reveals some abnormal condition as the cause of the pain. The acquired form may be the result of pelvic in­flammation, tumors of the ovary or uterus, or obstruction to free uterine drainage. Obstruction may be caused by scar tissue following surgery or by a small tumor in some part of the uter­ine canal, most often in the cervix.

Many cases of dysmenorrhea can be partly or wholly relieved without the aid of a doctor, and it is recommended that the advice given below be tried before consulting one. Correct health habits will do much toward making the female organs function properly and without distress. It is remarkable what favorable results sometimes follow the correction of constipation. Taking cold, exposure to cold or wet, mental stress, late hours, and dissipation are common causes of pain at the menstrual pe­riods, especially if they occur a short time before the flow begins; and one way to avoid such pain is obvious.

For the relief of pain, heat is the best local application. Heat or any other means of increasing the pelvic circula­tion will often help the flow to start; and, once the flow is well started, pain and other unpleasant sensations as a rule will gradually subside except in cases where obstruction is causing the trouble.

What to Do
1. Two days before the expected time for the flow to begin, reduce the amount of work done and in­crease the amount of rest. Take a warm tub bath or a warm half bath each evening for half an hour.
2. When the flow starts, go to bed and keep hot-water bottles to the feet and lower abdomen.
3. A hot saline enema will help both to clear the bowels and to re­lieve the pain.
4. Fomentation over the lower abdomen and lower part of the back often give relief from pain.
5. If distress persists after giving the above program a fair trial, con­sult a physician. He may find by examination that some obstruction is the cause of the trouble. If so, sur­gery may bring relief. If not, he may be able to give other useful advice, including the use of a mild anal­gesic.

ENDOMETRIOSIS.
Some comparatively young women, often sterile and troubled with irreg­ular and painful menstruation, are afflicted with this unusual condition, which is characterized by masses or patches of tissue similar to the endo­metrium (the membrane lining the uterus) .

These may be attached to the lower part of the colon, the ovaries, or other structures in the vicinity of the uterus. When the uterine lining goes through its regular changes, includ­ing swelling and bleeding, during the menstrual cycle, these masses or patches of tissue do the same, giving rise to pain and hemorrhage wherever they are located. A physician can usu­ally detect or at least guess at the con­dition by ordinary examination, but it may require surgical exploration to prove it.

What to Do
1. If irregular and painful periods are not known to have some other cause, a physician should study the case to detect possible endometriosis. The likelihood of it is greater if the woman concerned is sterile.
2. Medical treatment for suppress­ing of menstruation may relieve the distress, but the remedies used may have undesirable side effects.
3. Surgical removal of the abnor­mally placed tissue may be necessary.

FIBROID TUMORS OF THE UTERUS (FIBROMYOMAS).
Fibroid tumors of the uterus are composed partly of muscle tissue grow­ing from and resembling the muscle in the walls of the organ. Tumors of this sort are rarely found elsewhere in the body. With this special muscle tissue are intermingled varying amounts of fibrous connective tissue. Fibroids are usually multiple that is, several oc­cur at the same time in the same organ.

They vary much in size, from that of a pea to immense masses weighing two pounds or more. They are approxi­mately spherical in shape, except when influenced by pressure, and are firm in consistency. Their cause is not known.

They are hardly ever malignant.
When located in the lower part of the uterus, fibroid tumors are a source of danger during childbirth. If they are still lower down in the cervix or mouth of the uterus, they may press upon the bladder and the rectum. If located in the body of the uterus and close be­neath its lining membrane, they usu­ally cause profuse and prolonged men­struation, sometimes to the extent ofmenacing life from loss of blood.

The discomfort and the hemorrhage tend to increase until the sufferer must re­main in bed during the whole period of menstrual flow. There may be a feeling of weight in the pelvis, with backache; and, if the tumor is at all large, definite pressure symptoms may occur, such as irritation of the bladder, with a frequent sensation of need to urinate.

The pressure sensations in the rectum are somewhat similar, but they are accompanied by chronic constipa­tion. Pain does not come, as a rule, until the tumor has reached consider­able size. Chronic anemia is common because of the abnormally profuse menstrual flow. Leukorrhea may be troublesome between the periods.

What to Do
1. If the tumor or tumors cause no symptoms, no treatment is needed. They should be watched for changes, however.
2. No medicine or home treat­ment is of any use.
3. When symptoms give rise to a suspicion of the presence of fibroid tumors, consult a physician, prefer­ably a gynecologist. His examination will detect a tumor or tumors of any considerable size. Surgical removal is the only cure; and if the tumors are large or numerous, it may be necessary to remove the entire body of the uterus.

HEMORRHAGE FROM THE UTERUS.
Excessive bleeding from the uterus most often occurs in connection with the menstrual periods, in which case it is called menorrhagia. Bleeding at other times is called metrorrhagia. The most frequent causes of uterine hemor­rhage are the following:
1. Fibroid tumors, especially those located near the lining membrane of the uterus.
2. Uterine polyps.
3. Cancer of the body of the uterus, of which either menorrhagia or metror­rhagia may be a complication.
4. Hyperplasia of the endometrium, a condition in which the membrane lining the uterine cavity is overgrown, thick and soft, and full of blood ves­sels.
5. Ovarian cysts.
6. Retention of a portion of the pla­centa following childbirth.
7. General debility.
8. Endocrine gland imbalance.
9. Disordered circulation because of disease of the heart, liver, or lungs.

What to Do
1. For all sufferers from excessive menstrual flow, especially if they are debilitated, every possible effort should be made to build up the gen­eral health between periods, giving emphasis to moderate exercise, am­ple rest, and an abundant, nourish­ing, and easily digestible diet.
2. Between periods, a debilitated patient may benefit by a daily cold mitten friction.
3. More than the usual care is needed during and immediately af­ter any childbirth so that the uterus will be restored to its normal size and not become a large, soft, and soggy organ.
4. It is important to determine the cause of the hemorrhage. A physi­cian should study the case. Success­ful treatment will depend on deal­ing with the cause, and there is no single treatment that will succeed in all cases. Surgery or other treat­ments that can be given only by a physician may be needed.
5. Frequently the anemia produced by the excessive loss of blood re­quires special treatment.

PUERPERAL INFECTION.
The cause of puerperal infection is the entrance of disease germs, espe­cially streptococci, into the exposed tis­sues of the cervical canal and the uterine cavity at the time of childbirth, miscarriage, or abortion. It is practi­cally impossible to keep the vulva and vaginal tissues free from germs; there­fore the introduction of instruments, fingers, or other objects into the birth canal or uterus, while sometimes nec­essary, is always accompanied by some danger of infection. Proper care dur­ing delivery, however, would prevent most cases of puerperal infection.

Such infections are always serious and may be fatal. The inflammation may extend from the uterus to the ova­ries or to the tissues around the uterus, causing abscesses, and to the general peritoneum, resulting in peritonitis. In some cases the infection involves the large veins of the pelvis and the thighs, producing thrombophlebitis, or "milk leg”.

A woman who has apparently been doing well after delivery, a miscar­riage, or an abortion may have a rise of temperature, possibly preceded by a chill, on the third or fourth day. There may be no pain at all. The sudden rise in temperature in such a case indi­cates the strong possibility of puerperal infection and signals the urgent need for prompt professional care.

What to Do
1. If the symptoms give rise to a suspicion of puerperal infection, be sure that the woman concerned is under the care of a physician. Suit­able sulfas or antibiotics given early will usually control the infection.
2. Do not use vaginal irrigations of any kind without a physician's or­ders, and he is not likely to order them.
3. Give the patient all the water she will drink.
4. As long as acute symptoms per­sist, keep an ice bag applied to the patient's lower abdomen twenty minutes out of each hour.
5. The diet should be abundant, but should consist only of soft and liquid foods as long as the fever per­sists.
6. When the acute symptoms have subsided, keep the patient out in the open air as much as possible.

Diseases of the Oviducts

TUBAL PREGNANCY
In an occasional case of early preg­nancy the united sex cells fail to make their way into the uterus as is normally the case. In such event, the unborn child will begin its development wher­ever the united sex cells happen to lodge. This constitutes a so-called ectopic (misplaced) pregnancy. By far the commonest site for an ectopic pregnancy is within one of the ovi­ducts, where it is called a tubal preg­nancy.

The usual cause of a tubal pregnancy is that the oviduct is inflamed or so narrowed that the product of concep­tion does not have room to pass through the remaining portion of the oviduct and on into the uterus.

The hazard of tubal pregnancy is that the tissues of the oviduct are not designed to stretch as much as are those of the uterus. Thus, after about three months of development, the fetus has grown to such proportions that it causes the oviduct to rupture, produc­ing a serious hemorrhage for which prompt surgical treatment is the only satisfactory remedy. In the meantime, the unborn child perishes.

INFLAMMATORY DISEASE OF THE OVIDUCTS (SALPINGITIS).
Inflammation of the female repro­ductive organs occurs in connection with three kinds of infection: that of gonorrhea (60 percent of cases), that produced by streptococcic and staphy­lococcic organisms (35 percent of cases), and that of tuberculosis (5 per­cent of cases) .

Although more than one of the pelvic organs and their sur­rounding tissues may be involved, it is usually' the oviducts that are most se­riously affected. Such an inflammatory involvement of the oviducts is called salpingitis.

The germs of gonorrhea gain access to the female reproductive organs by way of sexual intercourse with a part­ner already infected with this disease. The germs first cause an infection of the tissues in the vicinity of the vulva and the lower part of the cervix of the uterus.

Then the infection follows the lining of the uterus upward and enters the oviducts, where it usually causes the greatest damage. It may continue through the oviducts to involve, the peritoneum and the ovaries. This in­volvement of the oviducts may occur promptly after the initial gonorrheal infection or it may occur some time later even years later. The lining mem­brane of the oviduct is virtually de­stroyed. There may be abscess forma­tion. The oviduct is no longer capable of transmitting the ova, and permanent inability to become pregnant is a usual complication.

Infection by streptococcic or staphy­lococcic organisms usually begins as a puerperal infection, in which these germs enter the tissues or the cervix of a uterus which has been unfortunately injured at the time of childbirth or mis­carriage or, more commonly, in con­nection with an abortion. In this type of infection the germs find their way into the tissues which surround the uterus and are then carried by the veins and lymphatic vessels to the ovi­ducts. The lining of the oviducts is not always destroyed in this type of infection, and thus in some cases it is still possible for the patient to become pregnant after the infection subsides.

Involvement of the oviducts by tu­berculosis is always secondary to a tu­berculous infection in some other part of the body, usually the lungs. The germs are carried to the oviducts by the blood. Early cases of tuberculous salpingitis may respond favorably to the administration of drugs now used for the treatment of tuberculosis in other parts of the body. Usually, how­ever, it becomes necessary sooner or later to have the involved tissues re­moved by surgery.

Symptoms of salpingitis vary some­what with the type of infection. In acute gonorrheal salpingitis the patient experiences severe pain in the lower abdomen with distension of the abdo­men. There is nausea, vomiting, fever, and rapid pulse.

In the septic type of salpingitis (that produced by strepto­coccus or staphylococcus organisms) the patient is weak with pelvic pain and possibly has chills along with the fever. In tuberculosis of the oviducts the symptoms are usually not as severe as in the other types, but pelvic pain is common and persistent, usually be­coming worse at the time of menstrua­tion. Sometimes there is excessive uter­ine bleeding. Often the complaint which brings the patient to the doctor is the inability to become pregnant.

What to Do

For the first two types of acute salpingitis the general program for the care of the patient is as follows:
1. Keep the patient in bed with the head of the bed raised eighteen or twenty inches higher than the foot (Fowler position).
2. Give the patient soft food in­cluding abundant fluid.
3. Take care to prevent the pa­tient's becoming dehydrated. Dehy­dration may occur quickly on ac­count of the vomiting.
4. Provide heat to the pelvic re­gion. The best method is by hot sitz baths in which the patient sits in a specially designed tub of hot water while his knees and legs hang over the edge of the tub. (At home, use hot tub bath, with patient sitting up. The tem­perature of the water should be grad­ually increased up to the patient's tolerance. The treatment should last about twenty minutes and may be given two or three time a day.
5. The physician in charge will doubtless prescribe a course of sul­fonamides and antibiotics chosen to combat the specific infection.
6. When the acute phase has passed, the physician may recom­mend surgical removal of damaged tissues and organs.
For cases of tuberculous salpingi­tis, the first motive in caring for the patient is to combat the tuberculous infection, using the general princi­ples of patient care mentioned in the chapter on tuberculosis .If the case is taken early, the physician will doubtless prescribe drugs effective in combating tuberculosis. Even in a late case, these drugs are useful as a preparation for the surgical removal of the pelvic organs involved in the infection.