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 HOWKINS & BOURNE
SHAW'S TEXTBOOK OF GYNAECOLOGY
 HOWKINS & BOURNE
SHAW'S TEXTBOOK
OF GYNAECOLOGY
Edited by

Sunesh Kumar, MD (AIIMS)

Professor and Chief Gynae Oncdlogj Services,
Depa rtment of Obstetr-lc.;:s ancJ Gynaecology,
All India lnstitut f ed1cal Sciences,
New Delhi

eritus Editars

S, FRCOG (LOND)
edor Professor and Head,
bstetrics and Gynaecology
ge Medica l College, New Delhi

Shirish N ry, , DGO, FICS, FIC, FICOG

er-i us Professor, Formerly Dean and Med1cal Advisor,
Nowrosjee Wadia Ma terni ty Hospi ta l, Mumbai
Past Presiden t, FOGSI

ELSEVIER
ELSEVIER
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Shaw's Textbook of Gynecology, 17e, Sunesh Kumar, VG Padubidri, and Shirish N Daftary

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Dedicated to my teachers, esfJecially Late Pmf Vera Hingomni
Preface to the 1 7th Edition
Sevemeenth Edition of this popular book "Shaw's Textbook of
O)"wecology" is in your hands. Writing prefuce tO this new
edition brings me t11e nosta lgic memo•) ' of my studem days
when all t11e studenlS read t11is book and when each word
wriuen in the book was like a statemem from experLS. Last
sixty years since first edition of t11e book has seen lot
of adva nceme nt in t11c speciali ty of gynaecology. fVF and
Endoscopic sw·ge•y arc two ve•) ' im porta nt advances which
has made speciali ty of gynaecology challe nging with a
bright fullt re.
I have made best effo rLS to update most of th e topics.
Such a n e ndeavo ur was possible o nly wit11 ac tive support
of Ill)' colleagues, reside nts and other staff. My special
t11anks are due to Dr. Ans hu Yadav, Dr. Aa nhi S Jayraj,
Dr. Ro hitha C and OLhe r Reside nts in my department for
VI
helping me reviewing the text, video recording and collect-
ing photographs. P•·ofessor San deep Mathur of Pat110logy at
AIIMS, New Delhi pr-ovided excellent coloured photomicro-
graphs.
l do not have enough words to express my t11anks to my
secreta•)', Ms. Sapna Gulati for doing w•·iting, editing and
correction work in t11e textbook in a p rofessio nal manne1·.
Special thanks are due to Ms. Shi va ni Pal and Ms. Sheenam
Agarwal of Elsevier Ind ia for their pa ti e nce and persistence.
Reali zing ex tre me hardshi p faced by students befo re
final examinatio ns a new secti on of Audi o-vis ual presenta-
tion o n important topics has bee n added.
Do se nd )'Our comm ents fo r im provingfuu.tre p ublications.
Smush Kwrwr
 Preface to the 16th Edition
\>\'e, the editors of Huwkins and Bounu Shaw's Textbook of
OynaecolQ(Jj) are pleased to acknowledge that this book has
continued tO provide basic foundation of this speciality
since 1936. Keeping in view of the popularity of the book,
tl1e first Lndian edition ( I 0'" edition) was published in
1989. Since then, tl1e book has been updated ft·om time to
tim e in tl1e ligh t of the adva nces made in tl1is speciality.
T he 15th editio n was revised in 20 10. O ur comm itm en t to
tl1 e swd enLS to improve a nd upda te the quali ty of th e
boo k, and provide th e m wi tl1 th e adva nced kn owledge
p ro mp ted us to b ri ng o ut the 16'" ed ition.
Ln tl1 is editio n, not o nly we have added the latest knowl-
edge o n tl1e subject, but also inse n ed mo re illustra tio ns,
flowc harts and tab les to make the read ing easie r and under-
standable. We have added mo re MRI, CT, and man y other
illusu<~tions wherever req uired.
Considering the high associated morbid ity and mortali ty
of gynaecological malignancies, we have approached the
topic of genital tract cancers more exhaustively in tl1is edi-
tion. Emphasis has also been laid on the gynaecological prob-
lems amongst adolescents and menopausal women. Minimal
invasive surgel} for the benign conditions is now being re-
placed b) non-surgical tl1emp) such as M RI~uided ablative
tllerapy without the need for hospitaliation. Hopefully ti1ese
procedures willwrn safe and effective in near future.
A website of the book has been created for more infor-
mation on tlle su~ect in the form of video clips, online
testing and MCQs for enu-ance tests and tile latest updates
on tlle subject.
We owe our special thanks to the entire staff of Elsevier
for tl1eir wholeheaned support and en couragement. We will
fail in o ur duty if we did not make a special reference lO
Shabina Nasim with whom we interact o n a daily basis and
also Re nu Rawa L. We appreciate their p rofessional atti tude
and the ir knowledge towards th e prqjec t, tl1e ir effi cie ncy
and enorm o us patience to bring o ut the best for th is
p roject.
Ou r veqr special tlHt nks and gra tiu.tde go lO Mr YR
Chadh a, Pub lis hi ng Cons ult.'llll, Bl Ch urchill Livingsto ne,
New Delhi, who in itiated and gu ided us in tile Firs t Indian
Edition in 1989, witho ut whose pers uasion and enco umge-
ment tl1is book wo uld not have seen tile day. There
are many others who have worked behind tile scene, we
acknowledge our thanks to them.
Last. but not ti1e least, we thank our readers and tl1e
student communiL) for their unstinted suppon over
the last 25 ) ears.
VG Padubidri
Shirish N Dajlary
VII
Preface to the 1Oth Edition
Ever since SltaiU~ Ttxtbook of C,•IWI'COiog)• a ppeared in Lhe
United Kingdom in 1936, it has maintained iLS popularity
with teachers, exa miners and th e student community.
ll has gone through several editions. The nimh edit.ion,
edited by Dr J ohn Howkins and Dr Gordon Bourne, was
brought out in 197 1, and its populat·ity in India has
remained undiminished. It is th erefo re timely and oppor-
tune tha t this standa rd textbook should be revised by
Indian teachers of gynaecology to meet th e requirements
of o ur unde rgraduate stude nts. We consider o urselves
fortunate for having bee n assigned thi s challe nging task b)'
th e publishers.
In revising tl1 e boo k we have e ndeavoured to upda te the
comenLS to include new metJ1ods of investigations and treat-
me nt. In particu lat~ recent advances in tlte physiology of
me nsu·uatio n and iLS hormonal co ntrol, carcinoma of the
cervix and related preve nLive meas ures, e ndo meuiosis, and
tlte management of wbe rculosis o f the genital u·act have
VIII
been incorporated. In additi on , the latest metl1ods of birtlt
control and a separate chapter on Medical Tennination of
Pregnancy have been added to equip our studenLS wilh Lhe
knowledge re qui•·ed to pr·o mote India's fa mil y welfare pro-
gramme.
We have also tded to make tlte text more concise by
deleting informati o n that we fell was unnecessa ry for tl1e
Indian undergradua te stude nt, witl10ut substamiall y chang-
ing the original style.
We are indebted to Mr YR Chad ha, Publis hing Director
of Bl Churchill Li vingsto ne, New Delhi for his constant e n-
couragement and inva luable suggesti ons in tl1 e preparation
of tl1 is edition. Since re thanks are exte nded to Ch urchill
Livingstone, Edinburgh, fo r Lheir assistance in making this
edition possible.
VG P(Ulubidri
Shirish N Daftary•
 Table of Content

Preface to the 17th Edition, vi SECTION 3 COMMON CONDITIONS

Preface to the 16th Edition, vii IN GYNAECOLOGY, 201
Preface to the 1Oth Edition, viii
16 Infertility- Male and Female, 202
Approach to a Gynaecological Patient,
0 How to toke Pop Smeor
17 Ectopic Gestation, 22 8
0 VIA ond VILU 0 Ectopic pregnancy

18 Acute and Chronic Pelvic Pain, 245

SECTION 1 ANATOMY, PHYSIOLOGY AND
DEVELOPMENT OF FEMALE 19 Temporary and Permanent M ethods of
REPRODUCTIVE ORGANS, 12 Contraception, 252
2 Anatomy of Female Genital Tract, 13
0 Loporoscopic tubol sterilization

0Bartholin's Abscess 0 Mini lop tubol sterilization

3 Normal Histology of Ovary and 20 Medical Termination of Pregnancy, 279

Endometrium, 37
SECTION 4 BENIGN CONDITIONS IN
4 Physiology of Ovulation and Menstruation, 48 GYNAECOLOGY, 285

5 Development of Female Reproductive Organs 21 Genital Prolapse ~ , 286

and Related Disorders, 61
22 Displacements of the Uterus, 302
6 Puberty, Adolescence and Related
Gynaecological Problems, 75 23 Diseases of the Broad ligament, Fallopian Tubes
and Parametrium, 308
7 Menopause and Related Problems, 86
24 Benign Diseases of the Ovary, 3 12
8 Breast and Gynaecologist, 99
25 Benign Diseases of the Vulva, 3 19
9 Sexual Development and Disorders of Sexual
Development, 106 26 Benign Diseases of the Vagina, 326

SECTION 2 DISORDERS OF SECTION 5 INFECTIONS IN

MENSTRUATION, 121 GYNAECOLOGY, 336

10 Common Disorders of M enstruation, 122 27 Pelvic Inflammatory Disease, 337

11 Abnormal Uterine Bleeding (AUB) 111!1 , 128 28 Tuberculosis of the Female Gen ital Tract, 347

12 Primary and Secondary Amenorrhoea, 141 29 Sexually Transmitted Diseases Including HIV
Infection, 356
13 Fibroid Uterus ~ , 155

14 Endometriosis and Adenomyosis, 174

15 Hormonal Therapy in Gynaecology, 188

IX
x TABLE OF CONTENT

SECTION 6 URINARY AND INTESTINAL TRACT 39 Radiation Therapy, Chemotherapy and Palliative
IN GYNAECOLOGY, 371 Core for Gynaecological Cancers, 494

30 Diseases of the Urinary Tract, 372 SECTION 8 IMAGING MODALITIES,

ENDOSCOPIC PROCEDURES AND
31 Urinary Fistula and Stress Urinary MAJOR AND MINOR OPERATIONS
Incontinence, 379
IN GYNAECOLOGY, 506
32 Injuries of the Genital Tract and Intestinal
40 Imaging M odalities in Gynaecology, 507
Tract, 396
41 Endoscopy in Gynaecology, 519
SECTION 7 GYNAECOLOGICAL 0 Diagnostic laparoscopy
MALIGNANCIES, 407
0 Diagnostic hysteroscopy
33 Preinvasive and Invasive Carcinoma
of Cervix l3,
408 42 Major and Minor Operations in
Gynoecology, 532
0 Colposcopy
0 Cervical biopsy-<:onisation
0 HPV testing
0 Total abdom inal hysterectomy
34 Cancer of the Body of the Uterus I!], 43 2 0 Vaginal hysterectomy for prolapse uterus
35 Pathology of Ovarian Tumours and Benign 43 Obesity and its Significance in
Ovarian Tumours, 44 1 Gynoecology, 54 1
36 Ovarian Malignancies, 459 44 Instruments Used in Gynaecology I!J, 545
37 Vulval and Vaginal Cancer, 472 Index 551
38 Gestational Trophoblastic Diseases, 481

To access th e vid eo:; and lecture PPT•, .can the •rmbols 0 and E prodded in the chapters.
 Approach to a Gynaecological
Patient
History Investigations 6
Physical Examination 3 Key Points 11
Gynaecological Examination 4 Self-Assessment 11
T he term gynaecology (from th e Gree k, gynae meanin g
wo man and logos mea ns discou rse) pe11_ains tO th e diseases
of women and is ge nerally llsed for disea es re laLed LO the
fe male gen iLal organs.
Th e interac ti on of a p ati ent with a p hysician can ofte n be
an a nxi ety-produ cing event, p articul arly so in Lhe prac ti ce
of gynaecology because of t he sensitive naLure of th e p rob-
le ms tha Lneed LO be disc ussed; he nce, th e o bserva nce of the
hig hes t standards of e thical and profession al be haviow· is
req uired to establish rapport, while no L creaLing a host.li e
enviro nm enL in which Lhe p aLi em fee ls embarrassed or t in-
comfo n able LO allow a meaningful assessmem of h er under-
lyin g medica l p roble m.
The fo llowin g fou r ethi cal principl es must be nt -
graLed into t he ca re and n amre of se rvices offered L
pa Lient.
1. Privacy and respect: Nowadays, co unsel-ling on s an
importa nL aspec t of consul tat.i o n. T he
aeco logical ail ment, reason fo r a
a nd iLS predi ct.i ve va lHe h ould b ms
sion on treatme nt options witif h ir d eritS a nd m er-
its will enable a wo ma n tO lOOS 1.h e treatment she
co ns iders besL for he1: The gy 1 co logist sh o11ld, h ow-
ever, guide her in ma king th e right decision. T he clini-
cia n mu.st respect the pa ti em as an individual. Re me m-
be r tha t th e pati e m has th e righL LO make dec ision
abo ut h er health care. lt is n ot eLhi cally or m orally right
to en force Lhe ph ysician 's opinion on the patien t. T l-lis
wil! safeguard agains t any ch arge of n egligen ce, if a
medi colegal problem arise a t a later date. T he records
should be prop erly main tain ed and th e doc umen rs
should be preserved. T h e pa tie nt should fee l assured at
a ll tim es a bout ' privacy and confidenti ali L)" . Talkin g
sofLly a nd pa t.i e ntly lisLening are of a great help .
2. Beneficence: The medical aLLendant must be vi gil ant
LO ensure that th e thera peutic advi ce re ndered to Lhe
pa ti ent should be in ' good faith '. It sh ould be aimed at
be nefiting her. Al l m edical m easu res a dopte d du ring the
course of medical u·eaune nt should be guided and evalu-
ated on the basis of th e principle of the cosL/ benefit
ra ti o acc ruing out of th e m edical advice given.
3. Justice: T his is r en th e ph ysician ma kes
access LO care, · re, the a ttention provided
and t.h e cost to the needs of the paLiem .
4. Avoiding · · dern Lim es, it is imporLant LO
avoid in eatm em which may lead to p os-
sible - · . For a d eLailed desc riptio n it is
a . oipt.i onsgiven by Ley P, Lipkin Mjt~
man R, Lewan M, Todd AD, Fish er S.
J-Sical examination constitute the ftmda men-
h rest th e tentaLive diagn osis, the tests to be
and th e treatm em to be recommended (Table 1.1 ).
Careful histo ry and p hysical examina Lion for m the basis
of pati ent evaluati on, clini cal diagn os is a nd manage ment.
lnvestigaLio n are ma de LO confi rm the di agnosis a nd for
th e fo ll ow-up of u·eatm enL
lt L~ advisable LO ask Lhe pati ent to desc ribe h e r main com-
plainL in her ovm words and take her own Lime narrating the
evo lution of the problem, the aggravating and re lieving fac tors
and the investigations and treatment she has already 1.mder-
gone. Good and patie m listening is essenti al to obtain maxi-
mum coop eraLion during th e sub.sequem pelvic examination.
Hist0ry begin with th e recording of th e basic informa-
tio n abo uL t11 e paLient as sh own in the samp le p roforma in
Table 1.1.
PRESENT ILLNESS
T h e clini cian must record th e patie m ' co mplainrs in th e
sequence in whi ch Lhey occ urred , no t.ing Lhe ir dura ti o n,
th eir aggravating a nd relieving fa ctors and th e ir relati o n to
m enstruation , micturiti on a nd defecati on. T he investiga-
tions pe rform ed and th e resp o nse to treatm ent given so far
sh ould be noLed.
PAST AND PERSONAL HISTORY
Pas Lm edical and surgica l p roblems may have a bearing o n
th e present complaints. For example, a history of di abetes
2 SHAW'S TEXTBOOK OF GYN AECOLOGY

Table 1.1 1 History: Gynaecological Case Record Fonn FAMILY HISTORY

Name
Presenting complaints:
Menstrual History:
Last menstrual period (LMP)
Present menstrual cycles
Previous menstrual cycles
Age at menarchae
Age at Menopause
Previous Obstetric History:
Full term deliveries
Preterm deliveries
Abortions (Spontaneous/
Induced)
Ectopic pregnancy
Living Issues
Contraception used:
Marital Status Cenain problems run in families, e.g. menstrual patterns
Married/Single/ tend to be similar amongst members of 1J1e family. Prema-
Age Unmarried tLtre menopause, menorrhagia and dysmenorrhoea may
occ~.u· in more than one member in a family. Similarly, fe-
male members of some families are more prone to cancer
of the oval'), uterus and breasL Diabetes, hypertension, tlly-
roid disorders, allel'gic diathesis and functional disorders
are often familial in nalllre. Genetic and hereditary disor-
ders affect more than one member in tlle family, e.g. thal-
assaemia. Tuberculosis may affect many members in the
family.
MARITAL AND SEXUAL HISTORY
Note tJ1e details of h er marital life such as the frequency of
coitus, dyspareunia, frigid it)', ac hieve ment of orgasm, libido,
use of contracepLives and the me thod used. T he releva nce
of dyspareunia to infe ttili t)' sho ul d be no ted.

Past Medical History: MENSTRUAL HISTORY

Diabetes
Hypertension
Thyroid disorders
Tuberculosis
Any surgery
Family History:
History of cancers In family
members
History of OM/hypertension
Personal History:
Smoklng
Addictions
Drugs
may suggest that pruritus vulva may be due to gen ital candi-
diasis, and history of sexuall y u·ansm iued disease (STO)
may have a direct bearing on future infertili ty.
History of pelvic inflammatory disease ( PID) or puer-
peral sepsis may be assoc iated with menstrual d isturbances,
lower abdom inal pain, co ngestive dysmenorrhoea and
inferti lity. T ube rculosis ma)' lead to oli go menorrhoea and
infertility. HistOr)' of e ndocrinopathy may affec t her sexual
fun ctions. Medi cal d iseases such as h)'pe n ension, cardiac
disease, anaemia, d iabetes, asthma and Lh e li ke will require
to be controlled before a plann ed st.u·gety Previo us b lood
u·ansfusion and drug a llergy should be noted. This has
special reference to H IV and hepatitis B infection.
Previous abdominal surgery such as caesarean section,
removal of tJ1e appendix and e xcisio n for ovarian cyst may
lead to pelvic adhesions, which may be t11e cause of ab-
dominal pain. backache, retroverted fixed uterus, infertili ty
and menstrual diswrbances. Dyspareunia is often tJ1e result
of pelvic adhesions.
Allergies to an> drug, Cll tTent medication, use of alcohol,
smoking, ch-ug abuse and lifest) le have relevance in t11e
management.
Normal menarche and me nstrua l cycle have been described
in Chapter 4.
The term me1wrrlwgill denotes excessive blood loss (in-
crease in duration ofbleeding/ heavie rblood flow) witho ut
any change in tJ1e cycle length. The term menorrhagia is
now replaced by 'abnormal uterine bleeding' (AU B) and
will be addressed in this chapter. The tenn pdymerwrrhoetl
or epimenorrlwea refers to frequent menstrual cycles as a
resuiL of shortening of the C) cle length. Sometimes women
suffer from a menstrual disorder characteriLed by a shorter
duration of the qcles coupled with a heavier flow or pro-
longation in tJ1e duration of the flow; this condition is
termed as po!Jmtllorrlwgill. The se,e,·ity of AUB can be
assessed by taking into account the number of sanitary pads
required per day, history of passing blood clotS, the pres-
ence of anaemia and evaluating the presence of accompa-
nying symptotns such as fatigue, palpitation, dizziness,
breathlessness on exertion and tJ1e presence of pallor.
Menorrhagia and polymenorrhagia are frequemly present
in women with m)'Oillas, adenomyosis and PI D in women
wearin g intrauterine co ntracep tive devices ( IUCDs) and
also due to hormonal imbalance ca using dysfunc ti o nal
uterine bleeding (DUB) in pcrimenopausa l women. AUB
now rep laces the wo rd DUB.
Oligomenorrlwea is the term used to describe infrequent
menses. ln this condition, the cycle lengtJt is prolonged
without affec ting the d uration and amount of flow. Hyj)(J-
me,wrrlwea refers to tJ1 e condition in which Lhe cycle length
remains unaltered; however, the duration of b leeding or the
amoLLnt of blood loss, or both are substantially red uced.
When the complete cessation of menstruation occurs, tlte
condition is described as amenorrhoea. The problems of
oligrmumorrlwea and h)1JOriU!1Wrrlwe(l are enco untered in con-
ditions such as pol)'l)llic uvamm di.S!XlSI! (PCOD), llyperprvlacti-
ntutmill and (jlmiuiltuberrulrui.s, in women on oral contracep-
Live pills, in association with certain neoplastns of tlle
pituitlll')' or ovary, in functional h) pothalamic disorders
and in ps)chiau·ic disorders. Ot·ugs may occasionally be
implicated. Oligomen01·rhoea and h) pomenorrhoea may
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT 3

occasionally progress to ame norrhoea. Amenorrhoea is

physiological during pregnancy, lactation, before puberty
and after menopause. Metrvrrlwgict (now addressed as inter-
menstrual bleeding) means the occurrence of intermen-
strual bleeding, and it rna> occur in association with ovula-
tion (mittelschmer£); however, it is commonly associated
with the presence of neoplasms such as uterine polyps, car-
cinoma cen ix and uterine and lower genital tract malig-
nallC)'· It may occur "ith conditions such as vascular ero-
sions, using intrauterine devices or breakthrough bleeding
in oral pill users. However, this S)lnptom calls for thorough
investigation because of a possible malignam cause. Some-
times the patient may present with the complaint of continu-
O!Ll bleffling, so that the normal pauem can no longer be
distinguished. Sud1 episodes may be of functional origin
due to h ormonal disturbances often willlessed as puberty
bleeding and perimenopausal bleeding disorders ( DUB).
However, during the chil dbearing years, co nditions due to
complications of earl)' pregnancy such as ec topic pregnancy
and abonion often present in this manner. Geni tal tract
neop lasms s uch as sub muco us polyps and ge nital malignan-
cies may present with co ntinuous bleeding. Postme1wpausal
bleeding is often re la ted to genital malignancy in 30%-40%;
hence, this S)'mpto m sho uld not be treated light!)', it sho uld
be evaluated carefulI)' and all efforts made to exclude such
a possibilit)'· Postcoita l b leeding often suggests cervical
lesion, i.e. erosion, polyp and cancer.
The presence of dysmenorrhoea and dyspareunia may
have orga11ic cause in the pelvis, i.e. endometriosis, fibroid
a11d PLD.
Vaginal discharge is common in lower genital u-act
infections.
OBSTETRIC HISTORY
Record the details of e'e•1' conception and its ultimate out-
come, the number of living children, the age of the young-
est child and the details of any obsteu·ic complications
encoume•·ed, e.g. puerpe1-al or postabo•·tal sepsis, postpar-
tum haemo•,·hage (PP H), obsteu·ical ime1ventions, soft
tissue injuries such as cervical tear, an incompetent cervical
os and repeated abortions, genital fistulae, complete peri-
nea l tear and genital prolapse, su·ess urinary inconti nence
and chronic backache. Severe PPH and obsteu·ic sh ock may
lead to pilllita•1' necrosis and 'Sheehan syndrome'. T hus,
man y a gynaecological proble m has its beginni ngs rooted in
earli er inadeq ua te obsteui c ca re.
Medical termination of pregnancy and spontaneous
abortions should also be enquired.
Abdominal pain: Abdom inal pain is a complain t in pelvic
tuberculosis, PID and endometriosis. Ac ute lower abdom i-
nal pain occurs in ectopic pregnancy, torsion or rupture of
all ovariall cyst and chocolate cysL
PHYSICAL EXAMINATION
Physical examination (Table 1.2) includes general exalnina-
tion, S)Stemic examination and gynaecological examination
"ith a female auendam presem to assist the patiem alld reas-
sw·e her, particularly so when t11e attending clinician is a
male doctor.
Table 1.2 Physical Exa mination
General Physical Examination
Height Weight
Pulse BP
Pal or Lymphadenopathy
Thyroid Breast
Systemic Examination
cardiovascular System
Respiratory System
Abdominal Examination
Inspection
Palpation
Percussion
Pelvic Examination
External Genitalia
Per Speculum Examination
Per Vaginal Examination
Per-rectal Examination
Provisional Diagnosis
GENERAL EXAMINATION
General examination includes data mentioned in the pro
forma (Table 1.2). Pallor of the mucous membranes, tl1e
tongue and conjunctivae toget11er witl1 pale appearance
ofthe skin and nails is high I) suggestive of anaemia, fullness
of the neck is suggestive of a thyroid enlargemem a11d
enlal·ged I) mph nodes are indicative of chronic infection,
tuberculosis or metastasis following malignancy. Bilateral
oedema of the feeL ma> be found in women witl1 lal·ge
abdominal tumours, and unilate•-al non pitting oedema is
highly suggesti,·e of malignant growth involving the lpn-
phatics. B•·east examination should be included in general
examination. Hi rsutism is a feature of PCOD. Breast secre-
tion is noted in hyperp•·olactinaemia, an importam feature
in amenon·hoea.
SYSTEMIC EXAMINATION
All gynae patients must be exa mined as a whole. This in-
cludes the examination of the ca rdiovascula r and I-espira-
tory systems. The p resence of any ne urological sy mptoms
calls for a de tailed ne uro logical evaluation, o t11 erwise test-
ing of tl1 e reflexes shoul d generally suffice. Li ve r s ho uld be
palpated in suspected maligna ncy for metastasis.
ABDOMINAL EXAMINATION
INSPECTION
Man y gynaecologicalwmours arising out of the pelvis grow
upwards into tl1e abdominal cavity. They cause enlargement
of the abdomen, particular!) the lower abdomen below tl1e
LUnbilicus. a11d their upper and lateral margins are often
apparent on inspection. Howe,er, very large wmours Call
give rise to a diffuse enlargement of the entire abdomen.
Pseudomucinous CJIIluletwma.s of the ovary can enlal·ge LO
malnmoth proportions, sometimes to an extent of causing
cardiorespiratory distress. E'ersion of the umbilicus Call
4 SHAW'S TEXTBOOK OF GYNAECOLOGY
occur as a resu lt of raised inu·aabdomina l pressure and is
observed with large wmours, ascites and pregnancy. The
mobility of the abdominal wall with breathing should be
observed carefully. In case of an intraabdominal tLLmOLLr,
the abdominal wall moves over the tumour during breath-
ing so that its upper margin is appare ntly altered. ln case of
pelvic pe •·ito n iLis. t11 e movements of t11 e lower abdomen
below the umbilicus are ofte n restricted. The presence of
striae is seen in parous women, pregnam women, in obese
suqjects and in women harbouring large tumours.
PALPATION
'•\lith the clinician standing on the •ight side of tl1e patient,
it is desirable LO palpate t11e liver, spleen and kidneys ,,;th the
right hand, and LO use t11e sensitive ulnar border of the left
hand from above downwards to palpate swellings a•·ising
from the pelvis. The upper and lateral margins of such swell-
ings can be felt, but t11 e lower border ca nnot be reached.
Myo mas feel firm and have a smooth surface, unless they
are mu ltip le, whe n tile)' present a bossed surface. Ovarian
neop lasms often feel cysti c, and may be flucwant. T he upper
margin oftheseswelli ngs is often we ll fe lt, unless the swelli ng
is too large. The pregnant uterus fee l~ soft and is known to
harden intermiuen tly during th e Brax to n Hicks contrac-
tion s; this is characte•istic of pregnanC)'· The fu ll b ladder
bulges in tl1e lower abdomen and feel5 tense and tende1:
£xu·eme tenderness on palpation below the umbi lict.LS is sug-
gestive of peritoneal irrit.ation , seen in women witl1 ectOpic
pregnancy, PLD, twisted ovarian cyst, a mptured corpLLS lu-
tewn haemaLOma or red degeneration in a fibroid often as-
sociated wilh pregnanC). In women witl1 an acute smgical
condition. guarding in th e lower abdomen and •igidity on
attempting deep palpation a re noted.
PERCUSSION
Ute•·ine m)•omas a nd ova•·ian C)SLS are dull tO percussion,
but the flanks a•·e resonanL Dullness in t11e flanks and shift-
ing dullness indicate t11e presence of a free fluid in the
peritoneal cavity. Ascites may be associated with tuberculous
peritonitis, malignancy or pseuclo-Meig S)'ndrome.
AUSCULTATION
This reveals peristalti c bowel sounds, fetal heart sounds in
pregnancy, souffle in vascular neoplasms and pregnant uterus.
Hyperperistalsis may indicate bowel obsuuction; feeble or
absent peristalsis indicates ileus, calli ng for aggressive atten-
tion. Retw·n of peristalti c so unds follo,,ing pelvic surgery is a
welcome sign of recovery and an ind ication to stan oral feeds.
GYNAECOLOGICAL EXAMINATION
Most prefer dorsal position, so that bimanual examination
of the pelvic organs can be concluctecl following abdominal
examination without changing t11e position. Some may pre-
fer left lateral (Sims' position). Verbal consent should be
obtained for bimanual examination.
EXAMINATION OF EXTERNAL GENITAUA
lt is a good practice LO inspect the external genitalia under
a good lighL otice the disu·ibution of pubic hair. Nonnal
pubic hair is distributed in an inverted u·iangle, with the
base cenu·ed over the mons pubis. The extension of the hair
line upwards in tl1e midline along t11 e linea nigra up to tl1e
tunbilictLS is seen in about 25% of women, especially in
women who are hirsute or mild!) androgenic as in PCOD.
Witl1 the patient in lithotOm) and he r thighs well paned,
note t11e variolLS su·ucwres of th e vulva. Look for the
presence of an) discharge or blood. Ask the patient to bear
down and obsen•e for any p•·oU'LLSion due tO pol) p or genital
descent such as cystocele, rectocele, ute•·ine descent or
procidentia. Separate t11e labia wide apart and examine
the fourcheue to see whether it is intact or reveals an old
healed tear.
SPECULUM EXAMINATION
Speculum examination should ideall y precede bimanual
vaginal examination especiall y when the Papanicolaou
( Pap) smear and vaginal smear need to be taken.
A bivalve self-retaining spec ulum such as CtL~co's spec ulum
is ideal for an office exa mination (Figs 1.1 and 1.2). It allows
satisfactory inspection of t11e ce rvix, ta king of a Pap smear,
colleCLion of the vaginal discharge from t11e posterior fornix
for hanging drop/KOI I smear and colposcopic examination.
Sims' vagina l spec ulum (Fig. 1.3) wi tl1 an anterior vagi-
nal wa ll retractor can be used for the above examination. lt
permits an assessment of Lhe vaginal wall for cystocele and
rectocele. However, an assistant is required to help the clini-
cian dttring this examination and t11e woman needs to be
brought to tl1e edge of the table. Stress-incontinence sho uld
be looked for especiall) in t11e presence of vaginal prolapse.
ln tl1is case. tl1e patient is e xamined with a full bladder.
BIMANUAL EXAMINATION
After separating the labia \\ith t11e tluunb and index fingers
of the left hand, two fingers of the •ight hand (index and
forefinger), after lubrication, are gradually introduced
be)ond the introitus to reach the fornices. If the fingers
encounter tl1e anterior lip of the ce•vix first, it denotes the
cervix is pointing dowmvards and back tOwards tl1e poste-
rior vaginal wall, and that t11e uterus is in tl1e antevened
position, conve•'Sely whe n t11e posterior li p of tl1e cervi.x is
encountered fi1'S4 it is indicative of a retroverted uterus.
Flgure 1.1 Cusco's speculum.
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT 5

Rgure 1.2 Speculum examination of the cervix. The patient is lying

in the dorsal position and a Cusco's speculum has been inserted into
the vagina. (Source: Mike Hughey, MD, President, Brookside Associ-
ates, Ltd.)

Rgure 1.4 Bimanual examination of the pelvis In the female. Two

fing ers of the right hand are Introduced Into the vagina and the left
hand is placed well above the symphysis pubi s. (Source: Swartz MH:
Textbook of Physical Diagnosis. Phiadelphia, WB Saunders, 1989,
p 405, Copyright Cl 2007 Saunders, An lmprnt of Elsevier.)

Flgure 1.3 Sims' speculum.

The clinician next observes the consistency of the cervix: it

is soft during pregnancy and firm in the nonpregnant state.
Observe whether the movementS of the cervi.x du•·ing the
examination cause pain; this is seen in an ectopic preg-
nancy, as also in women with acute salpingo-oophoritis. The
examining finge r'S now li ft. up th e cervix and th ereby ele-
vate the uterus towards th e left hand, which is placed over
t11e lower abdomen and bro ught be hind it (Fig. 1.4). T he
uten.rs can thus be brought within reac h of the abdo min al
hand and palpated fo r position, size, shape, mobility,
tenderness and t11e prese nce of any uterine pat11ology, e.g.
fibroids (Fig. 1.5).
ln case of tl1 e retroverted uterus, it will be felt through Rgure 1.5 Bimanual exam ination In the case of mult iple uterine
tlle posterior fornix. myomas. Note how the external hand Is placed high In the abdomen,
Thereafter, the cli nician directS the tips of the examin- well above the level of the tumour. Movements are transmitted
ing fingers in t11e vagina into eac h of the lateral fomices between the two hands directly through the tumour.
and, by lifting it up towards the abdominal hand, attemptS
to feel for masses in the lateral pan of the pelvis between The appendages are normally not palpable unless they
t11e two examining han cis. Should t11 is reveal t11e presence are swollen and enlarged. The ovary is not easily palpable;
of a swelling separate from t11e uterus, t11en t11e presence of however. when palpated, it evinces a peculiar painful sensa-
some adnexal patJ\OIOg) is confirmed. The common swell- Lion t11at makes the patient to wince. ext in tum is tlle
ings identified include ovarian C)St (Fig. 1.6) or neoplasm, palpation of tlle poster·ior fornix. This enables the palpa-
a paraovarian cyst, e.g. fimbr·ial cyst, tubo-<~varian masses tion of tlle contents of the pouch of Douglas. The most
(Fig. 1.7), h)drosalpinx, and swelling in chronic ectopic common swelling is the loaded rectum, panicularly if she
pregnancy. is constipated. Otllers in order of diminishing frequency
6 SHAW'S TEXTBOOK Of GYNAECOLOGY
Figure 1.6 Bimanual exam ination in the case of an ovarian cyst. The
nature of the tumour is determined on bimanual examination because
the uterus can be Identified apart from the abdominal tumour. Com pare
Fig . 1.5. In some cases the pedicle can be distinguished If the fingers
In the vagina are p laced high up in the posterior fornix. Movements of
the abdominal tumour are clearly not transmitted to the cervix.
Figure 1.7 Bimanual examination in the case of a pyosalpinx. Note
that the uterus Is displaced to the opposite side. The fingers in the
vagina are moved to one side of the cervl x, and they feel the lower
pole of the swelling.
include a reLroverted uterus, ovaries prolapsed into the
pouch of Douglas, uterine fibroid, ovarian neoplasm, choco-
late cyst of the ovary, endomeu·iotic nodules, pehic inflam-
matOt')' masses resulting from the adhesions of LUbo-ovarian
masses to the postet·ior surfuce of the uterus and the floor of
the pouch of Douglas, pelvic abscess pointing in the posterior
pouch and pelvic haematocele common!)' associated with a
ntptured ec topic pregnancy. To recogni:te the uterus from
ll1e ad nexal mass, push the cervix upwards, and if th is is trans-
milled to the swelling it is ll1e utems. Alternate!)', p ushing
down t11e ute ms causes the cervix to move down. Adnexal
mass does not move with cervical or uterine movement.
RECTAL EXAMINATION
ln virgins, a 'oaginal examination is avoided. Instead a well-
lubt·icated finger insened into the rectum can be used for a
bimanual assessment of the pelvic structures. No"oada)'S, pt-ac-
tically all gynaecologistS prefer ultrasonic scanning tO recta l
examination, which , apart from being unpleasa nt, is not that
accurate. A rectal examination is a very useful add itional ex-
amination whenever ll1ere is any palpable pathology in the
pouch of Douglas. It often allows the ovaries to be more easily
identified. In parameuitis and endomeu·iosis, t11e uterosacral
ligamentS are often thickened, nodular and tender. It con-
finns t11e swelling to be amerior to the rectum, and if the
rectum is ad herem to that swelling. This is important in case
of carcinoma of t11e ce tYix to detennine the extent of itS pos-
terior spread. A rectal examination is manclatOt')' in women
having rectal symptoms. This should begin by inspecting the
anus in a good light, when lesions such as fissures, fistula-
in-ano, polyps and piles may come to ligl1 L Introduction of
a well-lubricated proctoscope to inspect the rec wm and
anal canal helps to complete the examination. Ulu·asound
nowada)'S has reduced ll1e importance of rect.al exa mination
except in cancer of the cervix and pelvic endomeu·iosis.
INVESTIGATIONS
Detailed history and clinical examination often clinch the
diagnosis or reduce ll1e differential diagnosis to a few pos-
sibilities. However, investigations may be necessary to con-
finn ll1e diagnosis, to assess the extent of t11e disease, tO
establish a baseline for future comparison regarding the
response to a therapy and finall y tO de te rmine t11 e patiem's
fi mess tO undergo surgery.
Common disorders: Age re lated (see table 1.3 )
Table 1.3 Common Gynaecological Disorders-
Age Related
I. Adolescent and Prepubertal Girls
Vaginal d ischarge
Disorders of growth
Precocious puberty
Delayed p uberty
Sexually transm ltted diseases
Tumors of ovary, vagina and vulva
II. Reproductive Age
Disorder of menstruation
Ectopic pregnancy
Abnormal uterine bleeding
Contraception related issues
Infertility
Pelvic inflammatory diseases
Malignancies: GTN, Garcinoma Cervix, Ovarian Tumors
Ill. Menopause and Post Menopausal Age
Menopause related problems
Prolapse of uterus
Post menopausal bleeding
Malignancies: Cancer Cervix, Carcinoma Endometrium,
Carcinoma Ovary and Vulval Cancer
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT
Preoperative investigaLions are described in the chapter
on preoperative and posLOperative care. Special investiga-
tions are discussed as follows.
Special investigations:
• Special tests such as LUmour markers: CA-125 in sus-
pected adenocarcinoma of the ovary; carcinoembryonic
amigen (Cf.A), oc-fetoproteins and ~hCG in suspected
ov;uian teratoma and other germ cell tumours of ovary.
• Bacterial examinations of th e genital tract. These include
the following: (a) examination of the vaginal dischru-ge
for trichomoniasis; (b) 10% KO H-treated smear for de-
tecting candida; (c) I% b•illian t creS)'I violet for staining
trichomonad, but not the other bacte•ia and leucocytes;
(d) platinum loop for collection of discha•·ge (in sus-
pected gonon·hoea) from the urethra, ducts of Bartholin
and the endocervical secretio n fo r cul tu re on chocolate
aga•~ (e) immunofluo rescent examination of the dis-
charge of endocervical cells for suspected chl amydia!
infec tion; and (f) mi croscopic exa minati on of the clue
cells for diagnosis of bacte rial vaginosis (Chapter 9) .
Feinberg-Whi tti ngton mediu m is used for u·icho mo nad
and Nickerson-Sabouraud for candiasis. T he presence of
cl ue cells ind icates bacte•ial vaginosis.
Pol>•merase chain reacLion (PC R) staining has been
extensively utilized in the diagnosi.~ of various infections.
SPECIAL TESTS
HANGING DROP PREPARATION
ln women complaining leucon·hoea, the discharge collected
from the postel'ior fornix on the blade of the speculum
should be suspended in saline and submitted to microscopic
ex;unination. ormal 'oaginal discharge shows the presence
of exfoliated 'oaginal epithelial cells and the presence of
large rod-like lacLObacilli known as Doderlein's bacilli. A
fresh suspension of the discharge may reveal the motile flag-
ellated o•-ganisms known as TridwmQIWS vagina.l.is. Another
common cause of \'llginal infection is fungal infection or
vll{,riual cmulidir~:>i:>, this can also be detected f•·om a micro-
scopic examination of the vaginal discharge. To the suspen-
sion of the vaginal discharge, add an eq ua l amount of 10%
KOH soluti on. Place a drop of the mi xtu re o n a slide, cover
it with a cover sli p, wa nn the slide and exa mine it under the
low power of the microscope. T he KO H dissolves all cellular
debris, leaving be hi nd the mo re resista nt yeast-like organ-
isms. Typical h)•p hae o r m>•celia and b udding spores can
be easil)' detec ted. Many C<'lses of vagi nitis are attrib uted to
bacterial Vll{,rim},)i~ (nonspecific vaginiLis); also known as
Garrlnendla voginalil. The vis ua liz.1tion of 'clue cells' seen
preferably in a stained smear of the vaginal d isc harge is
high ly suggestive of the infection. Vaginal infections have
been discussed later in detail in Chapter 9.
PAPANICOLAOU TEST
Screening for Cancer
First described b) Papanicolaou and Traut in 1943, this
screening test is often •·efen·ed to as the 'Pap test' or a sur-
fuce biopsy or exfoliative C) tology (C) to logy is a Greek
word, meaning swdy of cells). It forms a pan of the routine
gynaecological examination in women. All sexually active
7
women older than 2 1 years should undergo an ann ual
check-up witl1 three yearly Pap test. Aside from premalig-
nant and malignant changes, otJ1er local conditions can
oft.en be recognized b) the cytologist. The Pap smear is
only a screening test. Positive test (abnormal cells) requires
further investigations such as colposcop)'• cervical biopsy
and fractional curettage. Unfonunately, the Pap test cru1
detect on I> about60%-70% of precancer and cance•· of the
cen~x and less than 70% of endomeu·ial cance•: Reliability
of the repon depends on the slide preparation and tl1e skiU
of the C) LOiogist. Although a single test yields as much as
10%-15% false-negathe reading, it is reduced to only 1%
with repeated tests. A false-positive finding is reponed in
the presence of infection. A yearly negative Pap sme;u· for
3 years is assuring, and thereafter 5-yearly test is adequate.
Th e Pap smear should be obtained before vaginal
examination, because the nngers may remove tl1 e desqua-
mated cervical cells and give a false-negative repo rt, lubri-
ca m may prevent de tec ti o n of orga nisms a nd a ny vaginal
bleedin g during exa min atio n may preclude a prope r visu-
a li zati o n of th e ce rvix. T he patient s ho uld no t have inte r-
co urse or to uch fo r 24 ho urs befo re the Pap test. T he bes t
time to do Pap smear is a ro und ov ulatio n, b ut any other
time can a lso do. T he patient is placed in th e do rsal posi-
tion, with the lab ia parted, and Cusco's self- retaining
spec ulu m is gemly introd uced witho ut the use of lubrican t
or jelly. The cervix is exposed; the sq uamoco lu mnar ju nc-
tion is now scraped with Ayre's spatula by rotating tl1e
spatula all around (Fig. 1.8 0). The scrapings are evenly
spread onto a glass slide and immediately fixed by dipping
the slide in the jar containing equal parts of 95% ethyl
alcohol and ether. After fixing it for 30 minutes, the slide
is air-d•;ed and stained with Pap or shon stain. The slide is
considered satisfact011, if endocen'ical cells are seen. To
improve the predictive valve, endocen'ix is also scraped
with a brush and added to the slide. owadays, a fixative
spray (cytospray) is a\oailable and can be used conveniently
in an office set-up. For honnonal cytological evaluation,
the scrapings are taken from the upper lateral pan of the
vaginal walls; tlwee types of cells are found in the normal
smear: (i) the basal and pa•-abasal cells are small, •·otmded
and basophilic wi th la •-ge nuclei; (ii) the cells from th e
mi ddle layer are squamous cells, tra nsparent a nd baso-
philic witl1 vesicular nuclei; a nd (iii) th e cells from th e
s uperficial la>•e •· are acidop hilic with charac teris ti c p yk-
noti c nuc lei. ln add ition, endome tri al cells, histiocytes,
blood cells a nd bacteri a ca n be seen . Malignant cells a re
hyperc hro ma ti c with a great increase in c hro matin co n-
te nt. Th e n uclei va11' in size a nd th e re is usua lly o nly a
s ma ll amo unt of C)'top lasm in the un d iffe re miatecl malig-
n am cell (Figs 1.9 and 1.1 0). T he nucle us/cytoplasmic
ratio is increased in malignant cells.
Papru1icolaou classincation:
Grade l Nonnal cells (Fig. 1.9)
Grade ll Slightl) abnonnal, suggestive of inflamma-
tOI") change; repeat smear after treating
tl1e infection
Grade Ill A more se•ious t} pe of abnonnality, usu-
all> indicative of the need for biopsy
Grade IV Distinctly abnonnal, possibly malignruu
and dennitely requi•·ing biopsy
Grade V Malignant cells seen (Fig. 1.1 0)
8 SHAW'S TEXTBOOK OF GYN AECOLOGY

R gure 1.8 (A) Papanicolaou sampling devices. Left to right: Cervix -Brush, Cytobrush, wooden spatula, plastic spatula, tongue blade and
cotton swab applicator. (B) Pap smear with a brush. (Source for (A): From Agure 16, Pre-prooedure. Prooedure ConsUlt. Pap Smear. Editors: Michael
L Tuggy and Jorge Garcia; Source tor (B): From Figure 1, Pre-prooedure. Procedure Consult. Papanicolaou Testing. Editors: Todd W Thomsen and

,,
Gary S Setnik.)
0 Scan to play How to take pap smear

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. :·.. '
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·l
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Rgure 1.9 Normal cervical smear showing superficial (pink) and intermediate (blue/green) exfoliated cervical cells (low power magnification).
(Source: From Agure 20·5, ian Symonds a"~d Sab.,.-atnam Arul<umaran: Essential Obstetrics and Gynaecology, 5th Ed. Elsevier, 2013.)

A newer classification (Tahlc I . I) describes the cytology
smears as follows:
1. Normal cyto logy
2. lnflam ma tOr)' smea r
3. Cervical inu·aepitJle lial neoplasia (CLN l) or mi ld dysplasia
4. Cl N ll, Ill and carcinoma in situ nuclear abno rma lities
5. MalignanL cells and tadpole ce ll~ wiLit nuclear abnor-
ma lities
lt is reasonable LO e nquire abo ut the percentage of
Lmsuspected cancers, including carc inoma in situ, that
are likely to be diagnosed on routine cytology. The In-
dian Council of Medical Researc h (LCMR). ew Delhi,
screened the population of women o lder L11an 30 years
and found 5-15 smears to be abnormal per 1000 women
examined. The incidence of d)Splasia reponed at Llle All
india l nsliune of Medical Sciences, ew Delhi, was
16/ 1000 patients screened. In a posunenopausal woman,
if the squamocolumnar junction is indrawn due to
oestrogen defici e ncy, a 10-day co urse of oestrogen cream
exposes th e squamocolumnar j un ction better a nd yields
a n acc urate resu lt. Pos trad iatio n cytology is d ifficu lt to
samp le because of sca rring and atrop hy of th e vagina.
T he cells are often e n larged, vacuo lated with mu ltip le
nucleation and nuc lea r wrinkling. InflammatOry cells
ma)' be present (Tab le 1.5 ).
Liquid-ba~ed C)>
tology us ing a thin preparation is s upe-
rior to Pap smear (Fig. I. II ). T he liq uid is used to screen
for papilloma virus. Cervical ca ncer screening is described
in Fig. 1.12. This is described in detail in Chapter 33.
Outer metJ1ocls of cervical screening are also described in
Chapter 33.
VISUAL INSPECTION AFTER ACETIC ACID APPLICATION
(VIA)
Gross inspection of cen·ix after application of 3% or 5%
acetic acid for I minute helps in detecting acetowhite area
which may harbour Cl / neoplasia.
 CHAPTER 1 - APPROACH TO A GYNAECOLOGICAL PATIENT 9

Table 1.5 Bethesda Classification

Sample-adequate, unsatisfactory
Squamous cell abnonnalities
Atypical squamous cells (ASC)
• Atypical squamous cells of undetermined significance
ASCUS
• ASC-cannot exclude high grade lesion ASC-H
• Low- grade squamous intraepithell al lesion (LSIL)
• Hlghijrade squamous intraepithellal lesion (HSIL)
• Squamous cell carcinoma
Adenocarcinoma

S01.rce: Bethesda G.Jideines.

Rgur e 1.10 Illustration of pathological grades of epidennoid cells in

the squamocolumnar junction of the cervix. Cells arising in this loca-
Figure 1.11 Liquid -based cytology classified as epithelial cell
tion were produced by a unifonn cell- scraping technique. Classifica-
abnormality, IOWiJrade squamous lntraeplt hellal lesion (LSiL) . Note
tion of cell types is based upon thorough study, eval uation of cell
particularly the cells in the centre. They have enlarged nuclei
characteristics and pathological features and Is final ly correlated wit h
compared with those in the cell s to the left and below. This feature is
corresponding histological studies of t he tissue. No attempt is made
required for a diagnosis of LSIL. The nuclear contours are irregular.
to classify cell s exfoliated from other tissue areas, such as the endo-
One cell to the right of centre is binucleated, a common feature in
metrium. The squamocolumnar junction Is a vital zone to the female
because this is the focal point where cancer arises. Grading of cell~
LSIL. (Source: From Figtre 12-1, Barbara S Apgar, Gregory L Brotzman
and Mar1< Spczer: Copoooopy: Prnc.,les and Practice, 2nd Ed.
depends upon knowledge of origin of cell sample, on securing a rich
Saunders Else>Aer, 2008.)
concentration of cells, and of greatest importance, correct correlation
with histological fi ndings.

PAP smear (liquid-based cytology with

HPV testing), start with sexual activity
at 30 years or any time after 2 1 years

Table 1.4 Comparison of Different Classification

System for Pre-Invasive Lesion
Papsm e ar Dysplasia CIN Bethesda

II

Ill M ild LS IL

IV Moderate II HSIL

v Severe Ill HSIL

L, low; H, high; SIL, squamous lntraepithellal lesion.

Figure 1.12 Cervical cancer screening.

10 SHAW'S TEXTBOOK OF GYN AECOLOGY

SCHIUER TEST (VISUAL INSPEOION AFTER LUGOL'S

IODINE APPLICATION - VIU)
0 Scan to play VIA and VILI
This test detects tl1e presence of glycoge n in the superficial
cells of tl1e vaginal epitJ1elium. The vagi nal wall is stained
wilh Ltago l's iodine (Lugol's iodine contains 5% iodine and
10% potassium iodide in water [l g iodine + 2g KI]). The
vaginal epiilielium takes mahogan) brown colour in Lhe
presence of gl)cogen. Unstained areas (nega tive LesL) are
abnormal and require biopsy for hisLological exa mination.

CYTOHORMONAL EVALUATION
The ovarian hormones oesu·ogen and progesterone influence
ilie vagin al mucosa; thus, the epitltelial cells exfoliaLed in the
vagina reflect the influence of the pt"C\'<liling dominam hor-
mone in the system at that Li me. The oestrogen-dominated
smear appear-s clea n and shows tl1e p r-esence of discreLe corni-
fied polygona l sq ua mes. The progesLerone-dom inaLed smear
appears cUny and reveals tlt e predom inance of in termed iate
cells. During p regnancy, t11e cytology smea r shows interme-
diate cells and navic ul ar cells. After Lhe menopause due to
tlte deficiency of u1e ova ri an ho rmo nes, tlte vaginal mucosa
tltins down and Ule exfo liated cells are predominantly para-
basal and basal t)•pes. In human papilloma virus (HPV)
infection, one can recognize ko ilocyLes with perinuclear
halo and peripheral conde nsatio n of cytoplasm. The
nucleus is irregular and hype rchroma tic (Fig. 1.10).
Karyopyknotic Index or KPI (Maturation Index)
11. is u1e ratio of mature squamous cells over tl1e imennedi-
aLe and basal cells. It is more tl1an 25% in proliferative
(oes u·ogenic) phase (Fig. 1.1 3) and low in secrewry
(progestational) phase (Fig. 1. 11) a nd during pregnancy.
During pregnanC)', a ratio of more tl1an 10% indicaLes
progesterone deficiency. onnally, a peak value of KPI
is reached on Ute day of ovulation (2 days after serum
E..! peak).
UTERINE ASPIRATION CYTOLOGY
Perimenopausal a nd posu11enopa usal women on a h or-
mone therapy are now being screened for endometYial
cancer. T he uterine aspiration syainge o r brush is fo und to
Figure 1.13 Hi stology of proliferative phase. (Courtesy: Dr Sandeep
Mathur, AIIMS.)
be sa ti sfactory for obta ining adeq uaLe sa mp les. lL can be
uti lized as an office p roced ure; abo ut 90% acc uracy with no
false-positi ve findings is cla imed with this proced ure .
COLPOSCOPY
T he colposcope is a b inocular microscope giving a 10-
20 times magnificatio n. It is useful in loca ting abnorma l
areas and accurately obtaining directed biopsy from tlte
suspicious areas on the cervix and vagina in women witlt
positive Pap smears. This wa> the frequency of false-negative
biopsy is reduced. so also the need for con iLaLio n, a proce-
dure Lhat is accompanied witJ1 considerable amoum of
bleeding and morbid it) (Chapter 18).
ENDOMETRIAL BIOPSY (Fig. 1.14A and B)
An office or outpatient procedure was aLone Lime very popu-
lat· in ilie investigations of the female panner for infea·LiliLy. 11.
is performed in Ute premenstrual phase. A fine cureue is in-
troduced into Ul e uterine cavity to obtain a small su·ip ofthe
endometrial lining for histopat11ological examination, sene-
tory endomeuium denotes ovulaLOry cycle. Witlt t11e avail-
abili ty of uluasoamd, a noninvasive method for tlte detection
of ovul ati on, U1is procedure is now generall y not employed.

A
Figure 1.14 (A) Histology of secretory phase. (B) Midsecretory endometrium. (Source for (A): Copyright 2009 by the Unillllrsity of Aorida)
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT
It is still used if tubercular endomeu·itis is suspected. It is
useful in the d iagnosis of co•-pus luteal phase defecL
HORMONAL ASSAYS
In presen t-day practi ce, it is possible to swdy the levels of
several hormo nes using radioimmun <><"1Ssays and/o r the
£ LISA tests. T he co mmo nly assayed ho m1 o nes include FSH,
LJ I, PRL, ACTH, T 3, T 4, TSH, p rogestero ne, oestradiol,
testosterone, cortisol, aldosterone, hCG, dehyd roepia nd ros-
terone and androstenedione. These ass;1ys are used in the
(Uagnosis of menopause, PCOD and prolactinomas, and for
monitoring treaunem regimes in induction of ovulation
and in assisted reproduction.
ULTRASONOGRAPHY
Ultrasonography is a simple noninvasive 11nd painless diag-
nostic procedure that has the advantage of being devoid of
any rad iatio n hazard. T he pelvis and the lower abdomen are
sca nned in bo th the lo ngitudinal and tra nsve rse planes.
Generally, th is scan is do ne when the pati e nt's b ladder is full
as it he lps to e levate th e uterus o ut of the pelvis, and dis-
places the gas-fi lled bowel loops away, thus provid ing the
sonologist with a window to image the pelvic organs. ln
most cases, a transvaginal probe can be tLSefully employed to
obtain finer details of the pelvic organs. The bladder need
not be full , if the vaginal probe is tLSed. The scan can
coll<lborate the clin ical impression or uncover a hitheno
tmsuspected pathology. Lately, •·ectal and perineal routes
are 11lso 11vailable. 0 3 ultraSound is now capable of provid-
ing three-dime nsional images of the pelvic o rga ns and is
recent! )' ava ilable especiall y to de tect ge ni tal trac t malfo r-
mati ons and is less costly than MRI. Ultraso un d is also used
in certa in tlterape utic procedu res such as in vitro fertiliza-
tion and asp iratio n of a C)'St or pelvic abscess.
OTHER IMAGING MODALITIES
Radiological investigation such as h)SterosalpingQgJ-aphy is
utilited for stud)ing the patency of the fallopian tubes in an
infertile patient. CT scan and MRI are advanced investiga·
tions that detenn ine the extent of tumours and their
spre<1d. For details, refer to Chapter 40. Sonosalpingog•-a·
ph y is employed in women with infe rti lity and wh en uterine
poi)'P is suspected.
GYNAECOLOGICAL ENDOSCOPY
Botlt diagnostic laparoscopy and hysteroscopy are estab Ushed
use ful tools in the armamentarium of t11e gynaecologist. For
details, refer to Chapter 41 (Endoscop) in Gynaecology).
11
PREGNANCY TEST
The first morning sample of urine is used in a •-apid immu-
nologi cal test to confirm pregnanC)\ by detecting the
presen ce of human cl1o1·ionic honnone. The pregnancy test
becomes positive by the begi nning of 6th week, from th e
last me nsu·ual period. With modem kits, any sample of
urine ca n be used, and it may beco me positi ve with in
1-2 da)'S after missing tl1 e pe riods.
KEY POINTS
• Most mnaecological diseases can be diagnosed by a
proper and detai led histor) and peh ic examination.
• While approaching a female patient, utmost care should
be taken to respect her feeUngs, ensure p•·hoacy and us-
ing simple words LO know details of her sexual hisLO•) ',
contraCeptive used, abortions and suq~ical u·eaunenL
• A wide range of investigati o ns are now <~vai l able with
Ute g)•naecologisLS which finall y co nfi rm the diagno-
sis, detec t the extent of th e d isease a nd help in plan-
ning tlt e managemenL
• Pap smear is now an established scree ning proced ure
in carcinoma cervix.
• Ulu·asound examinations have simplified gynaeco-
logical diagnosis.
• Seleahe ID naecological endoscop) helps defin itive
diagnosis.
• Honnonal assars are necessary in infertilitywork up, in
viu·o ferti litation and v:u·ious hormonal disturbances.
• Cr and MRJ have added to the imaging modalities
and are useful when diagnosis is in do ubt o n the basis
of ph)•Sical exa mina tio n.
SELF-ASSESSMENT
I. List t11e simple steps in history taking of a gynaecological
patient.
2. Describe the imponance of Pap smears in clinical practice.
3. WhaL is t11e role of imaging and endoscopy in the clinical
practice of gynaecolom•?
SUGGESTED READING
Ley P. Commun ications with Patient$. London, Croom I !elm, 1988.
Lipkin M .J r. The me dical interview and related skills. In BrdnCh "WT
(ed). Office Practice ofMedidne. Philadelphia. WB Saunders, 1987;
1287-306.
SirnpM>n M , Buck1nan R. Ste,.lart ~·f, ct al. Doctor paticnl communica-
tion. ThcTor<>nto consensus statcrnem. B:.tj 1991; 30!l: 1386-7.
Todd AD, Fi>hcr S. The Social Orgdnir.ation of Doctor-P:otienL Com-
munication, 2nd ed. ~onvood, ~- Ablex Publi>hing, 199!l; 243-65.
 ANATOMY, PHYSIOLOGY
AND DEVELOPMENT OF FEMALE
REPRODUCTIVE ORGANS

2 Anatomy of Female Genital Tract 6 Puberty, Adolescence and Related

3 Normal Histology of Ovary and
Endometrium
4 Physiology of Ovulation and
Menstruation
5 Development of Female Reproductive
Organs and Related Disorders
Gynaecological Problems
7 Menopause and Related Problems
8 Breast and Gynaecologist
9 Sexual Development and Development
Disorders of Sexual Development

12
 Anatomy of Female
Genital Tract

The Vulva 13 The Pelv ic Musculature 25

The Vagina 15 The Pelv ic Cellular Tissue 28
The Uterus 18 The Pelvic Blood Vessels 29
The Uterine Appendages 2 1 The Lymphatic System 3 1
Fallopian Tubes 21
The Ovaries 23
The Nerve Supply 33
Applied Anatomy and its Clinical 0
The Urethra 23
The Bladder 24
The Ureters 24
The Rectum and Anal Canal 25
Significance 33
Key Points 35
Self-Assessment 35 0
The anat0m ica! knowl edge of th e female genital organ the labia majora are hairless and the skin of
(Fig. 2. 1) and th eir relation to th e neighbouring structures t I area ·s ofter, moister and pinker th an over th e omer
help in the diagnosis of various gynaecological dise.ases~ ----,~ ( Fig. 2.2). T he labia majora are covered wiL11 squa-
and in interpreting the findings of u ltraso und , computed 1 11.s epithelium and contain sebaceous g lands, sweat
LOmography (CT) and magnetic resonance imaging ( glands and ha ir follicles. There are also certa in speci alized
scanning. During gynaeco logical surgery, di ronlons of the sweat glands call ed apocrine glands, which produce a cha r•
pe lvic organs are beuer appreciated and de.alt a d ac terislic aroma and from which th e rare tumour of hidrad-
grave inj1 11• to the sm.1 ctures uch as bladd enoma of the vu lva Ls derived. T he secre ti on in creases
rectum is avoided. Th e understanding of the l)Un hatic during sexual excitement.
drainage of the pelvic o rgans is necessa.i~ 1 rn~·ng arious The presence of all these su·u ctures in the labia majora
gen ital tract malignanc ies and in their ut ical d ssection. renders th em liable LO common skin lesions such as folliculitis,
boils and sebaceou cysLS (Fig. 2.3). LLS masculine coun terpart
i the scrotum.
THE VULVA

T he vulva is an ill-defined area which in gynaecological

practice comprises th e who le of the external gen itali a and
conveniently includes lhe perineum. It is, therefore,
bounded anteriorly by the mons veneris (pubis), laterally by
tl,e labia majora and posteriorly by the perine um.
LABIAMAJORA
T he labia majora pass from the mons veneris tO end poste-
1iorly in the skin over the perinea! body. T h e}' consist of
fo lds of skin which en dose a vairiable amount of fa Land are
best developed in the ch ildb earing period of life. ln chil-
dren before tl1 e age of puberty and in posunenopausal
women, the amo um of s ubcutaneous fa t in the labia majora
is relative!>• camy, and the cleft between the labia is there-
fore conspicuous. At puberty, pudenda! hair appear o n the
mons veneri , the outer surface of the labia majora and in
some cases on th e skin of the perine t:Lm as well. T h e inner
LABIA MINORA
Th e labia minora are thin folds of skin which encl ose ve ins
an d e lastic tissue and lie on the inner aspect of the labia
majora. T he vasc ular labia minora are erec tile during sexual
activity; they do not contain any sebaceotts glands or hair
follicles (Fig. 2.4). Ameriorly, they enclose the cliLOris to
fo rm the prepuce on the upper surface and the frenulum
on iL~ und ersurface. Posteriorly, they join tO form the fo 111~
chette. The fourc h ette is a tlli n fold of skin, iden tified when
th e labia are separated, and it is often rorn during parturi-
tion. The fossa navicnlaris is the small hollow between th e
hyme n and the fo urchette. Labia minora is homologous
with the ven u·a l aspect of the penis.
The clitoris is an erec tile organ and consists of a glans,
covered by tl,e frenulum and prepuce , an d a body whi ch is
ubcutaneous; it corresponds to th e penis and Ls attached LO
the und ersurface of the symph}•sis pubis by th e suspenso11•
ligament. ormally, the clitoris is 1- 11/1 cm long and 5 mm
13
14 SHAW'S TEXTBOOK OF GYN AECOLOGY

Uterus

Ovary
Rgure 2.1 General view of internal genital organs showing t he
normal uterus and ovaries.

Figure 2.3 Hi stological section of the labium majus showing squa-

Mons pubis
mous epit helium with hair follicle and sebaceous gland {X 55).
(wneris)

Prepuce
Frenum Clitoris
Vestibule _ ,._,1---,f+.- Labium majus
Labium minus -~i----+1 l.!l--1+-+1'- External urethral
orific.e
Vaginal introitus -..,.-+--1--SI
Opening of
Bartholin's duct
Hymen
1-+- -- - Perineum

Figure 2.4 Histological section of the labium minus showing squa-

8 Virginal Septate Cribriform Parous mous epithelium. Note complete absence of hair follicles and sebaceous
Rgure 2.2 (A) Anatomy of the vulva. (B) Variations of the hymen. and sweat glands.

in width. Clitoris o f more than 3.5 on in le ngth and I em
in width is called clitoro megaly, and occurs in virilism due to
excess o f androge n ho nno ne. The clitoris is well supplied
with nerve endings and is e xu·emely sensitive . Dlll·ing coiLUs,
it becomes e rect a nd pla)S a conside rable pan in inducing
orgasm in the female. The clito•·is is highl)' vascular. An in-
jury to the clitoris causes profuse bleeding and can be very
painful.
The ve~tibule is the space I) ing be twee n the anterio r and
the inner aspects of the labia minora a nd is bounded poste-
rioliy by the vaginal in troitus. The I'Xf t'rrUllurintt ')' 11U!lt iLIS iies
immediatel) posterio r to the clito •is. The vaginal orifice lies
poste,;or to th e meatus and is surrounded by the hp nen.
In virgins, the h)lne n is re p•-esellled b)• a thin membra ne
cove red o n each surface by sq uamous e pithelium. It gener-
a lly has a small eccenu·ic opening, which is usua lly not wide

enough to admit the fin gertip. Coitus resul ts in the rupture
of tl1e hymen; the resulting lace rations are radially arranged
and are multiple. Occasionally, coital n.apwre can cause a
brisk hae mo rrhage. During childbirtll, further lacerations
occur: tl1e h)lnen is wide!) SU'etched and subsequently is
represe nted b) the tags of skin kn own as the carunculae
myrtiformes. \\'ith the populaait) of tll e use of intemal sani-
tal")' tampons, the loss of in tegait) of tlle hpnen is no longer
an evide nce of loss of virginity.
The ' 'ulval tissues respond to ho nn ones, especially oestrO-
gen , during m e childbeaa·ing)ears. After menopause, auophy
due to oestrogen deficiency m akes me vulval skin tl1inner and
drier, and this m ay lead to atrophi c '~alvitis and itching. Mons
jJUbiJ is an at·ea which overl aps the symphysis pubis and con-
tains f.n. At puberty, abundant hair grow over it.
BARTHOLIN'S GlAND
Bartl1oli n 's gland li es posterolaterall y in relatio n to the vagi nal
otifice, deep to the b ul bospongiosus m uscle and supe rficial to
tl1e o uter layer of tJ1e u·iangu lar ligament. It is e mbedded
in the erec til e tissue of tJ1e vestib ular b ulb at its posterior
ex u·em it)'· It is norma lly impa lpable when healtl1y, but can be
readil)' palpated be twee n the finger and the tl1U mb when
en larged b)' inflammation. Its vascu lar bed accounts for me
brisk bleeding, which always accompan ies its removal. Its
duct passes forwards and inwards to open, external to the
hymen, on tl1e inne r side of the labium minus. The gland
measures about 10 mm in di.'lmeter and lies near tllejunction
of the middle and posterior thirds of tlle labium majus. The
duct of the gland is about 25 mm lo ng and a min mucous
secretio n can be expressed from it by pressure upon me
gland. Barth olin's gland and its duct are infected in acute
gonorrhoea, when the a·eddened mo urn of the duct can easily
be disti nguished on tl1e inner surface of m e labiwn minus to
one side of tl1e vaginal o aifice below the level of tl1e hpnen.
Bat·tllolin's gland is a compound racemose gland and its acini
are lined by low columnar epitllelium (Fig. 2.50 ) . The epi-
theliwn of the duct is cubical near the acini, but becomes
Rgure 2.5 Bartholin's gland. Low-power view showing the structure
of a oompound racemose gland with acini lined by low columnar
epithelium (x92).
0 Scan to play Barthol in's abscess
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 15
u·ansitional and finally squamo us near tl1e mouth oftl1e d uct.
The function of tl1e gland is to sec rete lubricating mucous
dwing coitus. The labia majora j o in at the posterior commis-
Sttre and merge imperceptibl) into tl1e peainea.un.
THE VAGINA
The vagina is a fibronnLSCular passage mat connects tl1e
Lllerus to me introitLLS. The lower end of the vagina lies at
the level of the h) men a nd of the inu·oitus \'llginae. It is sur-
rounded at tllis point by tl1e erectile tissue of tl1e bulb, which
corresponds to tl1e corpus spongiosum of the male. The
direction of the \':!gina is approxim ately parallel tO me
plane of tl1 e brim of tl1e u·ue pelvis; the vagina is slightl y
curved forwards from above downwards, and its anterior
and postetior walls lie in a close co nta ct. It is notofun ifotm
cali bre, being nea rly twi ce as capacious in i t.~ upper part and
somewhat flask shaped. T he vaginal ponio n of the cervix
projects into its upper e nd and leads to the fo rma tio n of th e
anterio •~ poste ri or and latera l forn ices. T he dep th of th e
forn ices depends upon the deve lopmen t of the portio vagi-
na lis of the cervix. In girls before pube r1.)' and in e lderly
women in whom the ute nts has undergone postmenopausal
atroph)', me fornices are shallow whe reas in women wim
congenital elongation of the portio vaginalis of tl1e cervix,
the fornices are deep. The vagina is attached to the cervix
at a higher leve l posteriorly than elsewhere, and this makes
the posterior fornix the deepest o f the fo rnices and tl1e
posterior \':!gina! wall lo nger than tl1e anterio r. The poste-
rior wall is 4.5 inch ( 11.5 em) lo ng, whereas Ll1e antet;or
wall measures 3.5 in ch (9 em). Transve rse folds which are
present in m e \'3ginal walls of nulliparae a llow the \':!gi na to
stretch and dilate during coitLLS and pat1.ut·itio n. These folds
are pa 11.ly o bliterated in women who have bome ma ny
children. In the a nteri or \':lgi nal wall, tllree sulci caa1 be
disting uished. One lies immediately above the meatus aa1d
is called ~ubmeaJal>ulctl> ( Fig. 2.6). About 35 mm above this
Rgure 2.6 A case of prolapse In which the cervix has been drawn
down. Parameatal recess, hymen, submeatal sulcus, paraurethral
recess, oblique vaginal fold , transverse sulcus of the anterior vaginal
wall, arched rugae of the vaginal wall and bladder sulcus.
16 SHAW'S TEXTBOOK OF GYN AECOLOGY

sulcus in tl1e ameli or vaginal wa ll is a second sulc us, known
as the transver:.e vaginal sulws, which corresponds approxi-
mately to the junction of the urethra and the bladder.
fLLrtller upwards is tl1e bltuhkr sulcus, indicating tl1e junction
of tl1e bladder to tl1e an tetior vaginal wall.
The vaginal mucosa is lined by nonkeratized squamous
epithelium which consists of a basal layer of cuboidal cells,
a middle la)er of prickle cells and a superficial layer of
comified cells (Fig. 2. 7). In the newborn, the epitheliwn
is almost transitional in t)pe and cornified cells are scanty
until puberty is reached. No glands open into the vagina,
and the \'3ginal secretion is derived partly from tl1e mu-
cous discharge of the ce•vix and partly from transudation
through tl1e vaginal epithelium. The subepithelial layer is
Epithelium
Submucous
la~r
Smooth muscle
(inner circular
and outer
longitudinal)
- } External
--~ -~ ~-::::::=:- fibrous layer
:::g~ -- -- ~ (endopelvic
--=---~-= -==-~--- tascia)
Rgure 2. 7 (A) Low-power {X36) microscopic appea-ance of the
vaginal wall showing the corrugated squamous epithelium and
bundles of plain muscle cells subjacent to the vascular subepithelial
layer. (B) Structure of the vaginal wall. (Courtesy for (A): Dr Sardeep
Mathur, AJIMS.)
vasc ular and contains much erectile tissue. A muscle
layer consisting of a complex interlac ing lattice of plain
muscle lies external to the subepithelial layer, whereas
the large vessels lie in the connective tissues surrounding
the vagina. If the female fews is exposed LO diethylstil-
boestrol (DES) taken b) the mother during pregnancy,
columnar epithelium appears in the upper two-thirds of
vaginal mucosa, which can develop vaginal adenosis
and vaginal cancer during adolescence. The keratiniza-
tion of vaginal mucosa occurs in prolapse due to the
exposure of vagina to the outside and ulcer may form
over the \'3ginal mucosa (decubitus ulcer). The keratized
mucosa appears skin-like and brown. Menopause causes
atrophy of tl1e vagina.
The vagiual .~ecretion is small in amount in healthy
women and consists of white coagulated material. Wh en it
is examined under a microscope, sq uamous cells sh ed from
the vaginal epi thelium and Doderlein's bacilli alo ne are
fo und. Duderlein~ !Jacillt.t.l is a large Gra m-positive rod-
s haped organism, whi ch grows a nae robicall y on ac id me-
dia. T he vaginal sec retion is ac id ic cl ue to tl1e presence of
lac tic ac id, and tl1is ac id it)' inhi b its th e growth of pa ul o-
ge nic organ isms. T he pl-1 of th e vagina ave rages abo ut
4.5 du ring reprod ucti ve life. T he ac id it)', which is undo ub t-
ed!)' oestrogen dependent, fa lls afte r me nopause to ne utt·a t
or even a lkaline. Before pubert)', the pH i.~ abo ut 7. This
high p l-1 before puberty and after menopause explains the
tendency for the development of mi xed organism infec-
tions in these age groups.
The synthesis of lactic acid is probably influenced by
either enzrme or bacterial activit) {Doderlein 's) on the
glycogen of the epithelial cells, which itself is dependem
on the presence of oestrogen, so that its deficiem activity
can be boosted b) the administration of oral or local
oestrogen. During the pue•·pe•·ium and also in cases of
leucorrhoea, tl1e acidity of the \'llgina is reduced and
pathogenic organisms are then able to survive. The squa-
mous cells of the vagina and cervix stain a deep brown
colour after being painted with iodine solution, owi ng to
the presence of glycogen in healthy cells (positive Schil-
ler's test). Ln a posUllenopausal woma n, because of tl1e
absence of or low glycogen-conta ini ng superficial cells,
Schiller's test becomes negative.
T he vagina l epithelium is under tl1 e ova rian hormo nal
infl ue nces of oestrogen and progestero ne. Oesu-ogen pro-
liferates the gl)'cogen-containing supe rficial cells and pro-
gestero ne causes prolife ratio n of ime rm ediate cells. Lack of
these ho rm ones in a me nopa usal woman leaves only the
basal cells with a thi n vagina l mucosa.
T he abno•mal and malignant cells also do no t con tain
gi)'COgen and do not take up lhe stain. Similarly, these
abnormal cells turn wh ite with acetic ac id d ue tO coagula-
tion of protein. These areas are selected for biopsy in the
detection of cancer.
RELATIONS OF VAGINA
ANTERIOR RELATION
In its lower half. the vagina is close!) related tO tl1e urethra
and the paraurethral glands {Skene's wbules), so closely in
faCL tl1at the urethr0\'3ginal fascia is a fused struCLure and
only separable by a sharp dissection. In its upper half, tl1e

vagina is related to the b ladder in the region of the u·igone,
and here the vesical and vaginal fasc iae are easily separable
by a blunt dissection via the vesicovaginal space. There is a
considerable vasc ular and lymph atic imercommunication
between the vesical and the vaginal vessels, a sinister rela-
tionship having a bearing on Lhe surgery of a malignam
disease of Lh is area.
POSTERIOR RELATIONS
The lower third of the \'llgina is re lated 1.0 Lhe perineal
body, the middle third 1.0 the ampulla of the reCLum
and the upper third to the anterior \\'llll of the pouch of
Douglas, which comains la•·ge and small bowel loops. This
partition dividing the vagina from the pe•·itOneal cavity is
tl1e thinnest a•·ea in the whole pe•·itOneal surface and,
tl1erefore, a site of election for poim ing and opening of
pelvic abscess or th e productio n of a h ernia or enterocele.
T his is also an ideal site for colpocem esis in th e d iagn osis
of ectOpic pregnancy.
Pouch of Douglas (Fig. 2.8) is a pe rito neal cul-de-sac in
the rec tovaginal space in the pelvis. IL is bo unded anterio rl)'
by the peritone um cove rin g the pos te rio r vaginal wall and
posLerio rl )' b)' tl1e peritone um covering the sigmoid colon
and the recwm. Laterall y, th e uterosacral ligame nts limi t
its bo undary whereas th e floor is Lhe reflection of the
peritoneum o f the pe rito neal cavity.
The endometriotic nod ules and metasmtic growth of
an ovarian cance r are fe lt in tl1 e pouch of Douglas, so
also pelvic inflammatOI') mass. The u1.erosacral ligaments
are thickened and become nodular in advanced cancer
cervix.
LATERAL RELATIONS
The la1.eral relations f•·om below upwa rds are the cavern-
ous tissue of the vestibule; the supe •·ficia l muscles of the
pe•·ineum; the u·iangu lar liga ment and at about 2.5 em
from the inu·oitus t11 e Je,>aLOr ani, lateral tO which is tl1e
ischio•·ectal fossa. Above the levator lies the endopelvic
cellular tissue, and its condensation , called Mackenrodt's
ligament, on tl1 e either side. The ureter traverses this
Uterosacral ligament Pouch of Douglas
Figure 2.8 Pouch of Douglas showing uterosacral ligaments as
upper border.
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 17
tissue in the urete ric ca na l and is abou t 12 mm anterolat-
eral to the lateral fo rnix.
SUPERIOR RELATIONS
1l1e cervix with its four fornices - amerior, posterior and
two lateral- are related to tl1 e uLerine vessels, Mackenrodt's
ligament and the ~.u·e ter. PosLe•io rl), surrounding the pouch
of Douglas lie the uterosacral ligaments which can be identi-
fied o n vaginal examination, especiall)• if thickened by
disease such as endomeu·iosis and cance r ce rvix.
Squamocolumnar j unction, also known as u-ansitional
zone, is clinically a ' ery important junction where the squa-
mous epithelium lining tl1e vagina merges witllthe columnar
epithelium of tl1e endocervix and is 1-10 mm (Fig. 2.9) .
Here, tl1e constant cellular activiLy of tl1e cells takes place,
and the cells are highly sensitive to irritants, mutagens and
viral agents such as papilloma virtL5 16, 18. T hese agents cause
nuclear changes tl1at ca n evenLUall y lead tO dysplasia and
carcinoma cervix, which is the most co mmon malignancy of
tl1e female geniLal tra ct in Ind ia. Squamocolumnar junction
is of two types: first one is embryo nic when columnar epithe-
lium spreads over the exte rna l os. Afte r pube rt)\ metaplasia
of colu mnar epitl1e liu m unde r the infl uence of oestroge n
brings sq uamous epitheliu m close to Lhe ex ternal os, thus
creati ng a u·ansitional zone be twee n the two j unc tions. In
women exposed to DES in utero, tl1is zone is well outside the
os, spreading over tl1e \'llgi nal vau lt. In a menopausal woman,
it gets indrawn inside tlle os. During pregnancy and with oral
conu-aceptives, it pouts o uL of os.
The squamoco lumnarjunction is well outside me external
os dLLring tl1 e reprod uctive period, and in Pap smear tl1is area
is scraped and tl1 e C) tolog) of its cells swdied for the nuclear
changes, in me scree ning programme for ca nce r cervix.
Dw·ing pregnane), tl1e ex1.e m al os becomes patulous and
the squamocolumnar junction is well exposed all round.
Pap smear> ields the most accu rate C) tological findings.
ln menopausal women, the cervix sh•·inks and the squa-
mocolumnar junction gets indrawn into the cervical canal.
Columnar
epithelium
Figure 2.9 Squamocolumnar junction. In the 'ideal' cervix, the
original squamous epithelium abuts the columnar epithelium. (Soun::e:
Hacker NF, Ganbone JC, Hobel CJ, Hacker CW'ld Moore's Essentials ot
Obstetres ard Gynecology, 5th ed Pliladelphia: Elsevier, 201 0.)
18 SHAW'S TEXTBOOK OF GYN AECOLOGY
lt is therefore not easily accessib le, and ill exposed to the
vagina, for visua l inspection. This explains high false-nega-
tive findings in Pap smear in older women. Giving oestrogen
locally or orall) or prostaglandin E (misoprosLOI) pessary
allows this junction to pout out and improves t11e efficacy of
t.he Pap smear C) to log).
The squamocolumnarjunction is SLUdied colposcopically
when t.he Pap smear shows abnormal cells, and t11e abnor-
mal areas are biopsied fo•· cancer detection.
THE UTERUS
The uterus is py.-iform in shape and measures approxi-
mate!)' 9 em in length, 6.5 em in width and 3.5 em in
tl1ickness. It is divided anatom icall y and fun ction all y
into body and ce1vix. It weighs I o unce (60 g). T he line
of division correspo nds to the level ofth e intern al os, and
here the muco us membra ne lining the cavity of the
uter us beco mes con tinuo us witl1 that of th e cervical ca nal
(Fig. 2.1 0). At thi s level, the pe ri to ne um of the front of
t11e ute rus is reflected o n to the bladde r, a nd the uterine
artery, after passing a lmost tra nsverse!)' ac ross the pe lvis,
reac hes tl1e uterus, tu rns at r ight angle and passes verti-
cally upwards a long the latera l wa ll of the u terus. T he
ce1vix is divided into vagina l and supravaginal portions.
The fundus of the uterus is that part of the corpus uteri
which lies above the insertion of the fallopian tubes. The
cavity of t11e uterus communicates above wit11 t11e open-
ings of the fallopian tubes, and by way of t11eir abdominal
ostia is in direct con tin uit) with t11e peritOneal cavity. The
uterine caviL) is triangular in shape witll a capacity of
3 mL. The lower angle is formed by the internal os. The
lateral angle connecting to the fallopian tube is called t11e
cornual end. The wall of the uterus consistS of tluee layers,
t.he peritoneal co,·ering called pe•·imetrium, tl1e muscle
layer or myomeu·ium and t.he mucous membrane or
endomeu·ium.
The ute•·us is capable of distension during pregnancy,
haematometra as well as with distended media du.-i ng
hysteroscopic examination. Otherwise tl1e two walls are in
opposition.
Infundibulum Intramural
(Interstitial) par t
-4::::~-- Cervical canal
Vaginal cervix or
(portio vaginalis)
Rgure 2.10 A nulliparous uterus showing the anatomical structures.
PERITONEAL COVERING
The peritoneal covering of the utems is incomplete. Anteri-
orly, t11e whole bod) of t11e ULerus is covered witll peritoneum.
1l1e peritoneum is reflected on to t11e bladder at t11e level of
t.he imemal os. ll1e cen1x of t11e uterus has t11erefore no peri-
toneal covering ameliorl). Post.e•iorl), tl1e whole body of t.he
uterus is covered b) pelitoneum, as is the supravaginal portion
oft.he cen·ix. The pel"itoneum is reflected from t.he supravagi-
nal portion of t.he eel"\ ix on to the poste•·iorvaginal wall in tl1e
region of t.he postelior fomix. The peritOneal la)er is incom-
plete laterally because of the insertion of t.he fallopian tubes,
t.he row1d and ovarian ligaments into t.he uterus, and below
t.his level tl1e two sheets of peritoneum, which constitute t.he
broad ligament, leave a tl1in bare area laterall y on each side.
MYOMETRIUM
T he myome u·ium is the thickest of t11e t11ree laye rs ofthe wall
of the ute n.ts. ln the cen>ix, the m>•ometrium consists of plain
muscle tissue together witJ1 a large amo unt of fibrous tissue,
which gives it a hard consistency. T he muscle fibres and
fibro us tissues are mixed togctJlcrwithout an orderl)' arrange-
menL ln tJ1e bod)' of tJ1e utenJS, tJ1e myomeuium measures
aboutl 0-20 mm in tJ1 ickness, and tJ1ree layers can be d istin-
gu ished which are best marked in tJ1e pregnam and puerperal
uterus. The extemal layer lies immediately beneath the peri-
tonewn and is longitudinal, tJ1e fibres passing from t11e cervix
anteriorly over tl1e ft.uldus to reach tJ1e posterior surface of
the cervix. ll1is la)er is Lhin and cannot easily be identified in
ilie nulliparous uterus. The main function of tJ1is layer is a
dem.ISor action during tJ1e expulsion oftJle fetus. The middle
layer is t.he thickest of the tJwee and consists of bLUldles of
muscle sepamted b) a connecti'e tissue, the exact amow1t of
whid1 varies with age; plain muscle tissue is best marked in tl1e
childbearing pe•iod, especially during pregnancy whereas
before pubeny and after menopause it is much less plentiful.
There is a tendency for tJ1e muscle bundles to imerlace, and
as t.he blood vessels supplying blood to the uterus are dist.lib-
uted in the connective tissues, tJ1e calibre of the vessels is in
part controlled by tJ1e conu<~ction of tJ1e muscle cells. The
purpose of tl1is la>•er is therefore in part haemostatic, tl1ough
its exp ulsive role is equally importa nt. T his layer is clesclibed
as living ligal!tm~ of the uteno, and is responsible for comrol of
bleeding in the thi rd stage of labo ur. Inefficient contrac tion
and re u·act.i on of these muscle fib res ca use prolonged labo ur
and atOni c postpartwn haemo •Thage (PI)I-1).
T he inner muscle la>•er COI1Sists of circula r fib res. T he
layer is never we ll marked and is best rep rese med by tl1 e
circ ular mt.ISc le fibres around the in te rnal os a nd tJ1e ope n-
ings of the fallopian tubes. It can be regarded as sp hin cteric
in action. The myomeui um is th ickest at the fund us
( 1-2 em) and thinnest at tJ1e cornual end (3-4 mm), one
should t11erefore be careful during curettage and endome-
trial ablation not to perforate tJ1e com ual end.
ENDOMETRIUM
The endomeu·ium or mucot.IS membrane lining tJ1e ca'~t:)'
of the uterus has a different structure from that of tl1e
enclocervix. It is described in Chapter 3, ' onnal histology
ofOvaryand Endometdum'.

The cer vix is spind le shaped and measures 2.5 em or a
little more. It is bounded above by the internal os and
below by the external os (Fig. 2. 10). The mucosal lining
of tJ1e cervix differs from that of the body of tJ1e uterus by
tJ1e absence of a submucosa. The endocervix is lined by a
single la)er of high columnar ciliated epitJ1elium \vith
spindle-shaped nuclei I) ing adjacent to the basement
membrane with abundam C)LOplasm and mucin. The
direction of the cilia is downwards towarcls the external
os. The glan<ls are racemose in t) pe (Fig. 2.llA and B)
and secrete mucus with a high content of fructose glyco-
protein, mucopolysaccharide and sodium chlo•·ide. The
secretion is alkaline and has a p H of 7.8 and itS fructose
contem render·s it atu-active to ascend ing spe•·maLOzoa.
This secretion collectS as a plug in the cervical ca nal an d
possibly h inders ascending infections. In gonococcal an d
chl amydia! infections of th e ce rvix, tJ1 e orga nisms collect
amongst t he cryptS of th e cervical glands. In nulli paro us
~ .
" . . .
- - ·. ,~ .
:c..•·
·· "'..
-.•
' between tl1e endomeuium of the body and the mucous
Rgure 2.11 (A) Normal endocervical cells. (B) Normal cervical
glands. These are of the racemose type and are lined by high co-
lumnar epithelium which secretes mucous (X250). (Source tor
(B): Seama Khuni, CervtxPremalignCW"It/preinvasive lesions. 2003-
2017, PalhologyOutlines.com, Inc.)
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 19
women, the external OS is circ ular b ut vagina l de livery
resul tS in tJ1e transverse slit which characterizes the paro us
cervix. The cervix contains more of fibrous tissue and col-
lagen than the muscle fibres, which are dispersed scarcely
amongst the fibrous tissue. Cervix contains mainly colla-
gen and on I) 10% of muscle fibres. Light microscopic ex-
amination reveals 29% muscle fibres in itS upper one-
third, IS% in tJ1e middle one-third and only 6% in the
lower one-tJ1ird, whereas the body of me utems contains
70% muscle fibres. The change from fibrous tissue of cer·
vix to the muscle tissue of the body is quite abrupL ln late
pregnancy and at tenn, under the influence of prostagla n-
din, collagenase dissolves collagen into fluid form a nd
renders tJ1e cervix soft and stretchable during labour.
Functions of the endoce•·vical cell li n ing are as follows:
• T he cilia are directed downwards and prevent ascending
infection.
• T he cells sieve o ut abnormal sperms a nd allow h ealthy
sperms to en ter the uterus.
• It provides nu ui tio n to the sperms.
• It allows capaci tati o n of spe rms.
Structu rall)' and func ti onally, tl1e bOd)' ofLhe ute rus and
that of tl1e cervix are in marked contrast. T he ce rvical epi-
the liu m shows no periodic alteration d uri ng the mensu·ual
cycle, and the decidual reaction of pregnancy is seen o nly
rarely in the cervix. Similarly, t11e malignant disease of tl1e
uterus is an adenocarcinoma of the endometrium, whereas
carcinoma ofthe ce1vix is usuall) a squamous cell growtl1 of
high malignrulC).
An intennediate Lone, tltl' istlm1us, 6 mm in length, lies
membrane of the ce•' ical canal. ItS epitJ1elial lining resem-
bles and behaves like the endomeu·ium of me body. The
isthmic po•·tion stretches cllll·ing pregnanq• and fonns tJ1e
lower uterine segment in late pregnancy. This isthmic por·
tion is less contractile dlll·ing pregnancy and labour but
funher stretches under uterine conu-actions. It is identified
during caesarean delivery by the loose fold of pe•iwneal
lining cove•·ing itS amel"ior surface.
The relationship between the lengtll of the cenrix and that
of me body of tJ1e uterus '"''ies with age. Before pube11.y, the
cervix to co•pus ratio is 2: 1. At pubeny, tJ1is ratio is reversed LO
1:2, and during the reproductive years, ce•vix to corp us ratio
may be 1:3 or even 1:4. Afte r me nopa tL~e. tl1e whole organ
atrophies and tl1e portio vagina lis may eventuall y d isappear.
Al tl1o ugh the endomeui al sec retio n is sca nty and fl uid in
na ture, the cervical sec reti on is abunda nt and itS q ua li ty and
q uantity change in the d ifferen t phases of tl1e menstrua l cy-
cle, under d ifferent hormonal effectS. T he cenrical mucous
is rich in fntctose, glycoprotein a nd mucopolysacc harides.
Fructose is n utritive tO sperms cl uling tl1eir passage in me
cervical canal. Under oesu·ogenic infl uence in the preovula-
LOry phase, tJ1e glycoprotein network is arranged parallel to
each otJ1er and facilitates sperm peneu-ation, whereas under
the progesterone secretion, t11e network forms interlacing
b1idges and prevents their entr) into the cen~cal canal. This
prope•1.) of progesterone is ttSed in a contraceptive pill a11d
progesterone-impregnated in u-aute•ine conu-aceptive de-
vice. Sodium chlol'ide coment in the mucous increases at
ovulation and fonns a fem-like pattern when a drop of mu-
cous is dried on a slide and studied under a microscope.
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California Joe aspired to, or, considering some of his undeveloped
traits, was equal to; but I am anticipating.
As the four detachments already referred to were to move as
soon as it was dark, it was desirable that the scouts should be at
once organized and assigned. So, sending for California Joe, I
informed him of his promotion and what was expected of him and his
men. After this official portion of the interview had been completed, it
seemed proper to Joe’s mind that a more intimate acquaintance
between us should be cultivated, as we had never met before. His
first interrogatory, addressed to me in furtherance of this idea, was
frankly put as follows: “See hyar, Gineral, in order that we hev no
misonderstandin’, I’d jest like to ask ye a few questions.” Seeing that
I had somewhat of a character to deal with, I signified my perfect
willingness to be interviewed by him. “Are you an ambulance man ur
a hoss man?” Pretending not to discover his meaning, I requested
him to explain. “I mean do you b’leve in catchin’ Injuns in
ambulances or on hossback?” Still assuming ignorance, I replied,
“Well, Joe, I believe in catching Indians wherever we can find them,
whether they are found in ambulances or on horseback.” This did not
satisfy him. “That ain’t what I’m drivin’ at. S’pose you’re after Injuns
and really want to hev a tussle with ’em, would ye start after ’em on
hossback, or would ye climb into an ambulance and be haulded after
’em? That’s the pint I’m headin’ fur.” I answered that “I would prefer
the method on horseback provided I really desired to catch the
Indians; but if I wished them to catch me, I would adopt the
ambulance system of attack.” This reply seemed to give him
complete satisfaction. “You’ve hit the nail squar on the hed. I’ve bin
with ’em on the plains whar they started out after the Injuns on
wheels, jist as ef they war goin’ to a town funeral in the States, an’
they stood ’bout as many chances uv catchin’ Injuns az a six-mule
team wud uv catchin’ a pack of thievin’ Ki-o-tees, jist as much. Why
that sort uv work is only fun fur the Injuns; they don’t want anything
better. Ye ort to’ve seen how they peppered it to us, an’ we a doin’
nuthin’ a’ the time. Sum uv ’em wuz ’fraid the mules war goin’ to
stampede and run off with the train an’ all our forage and grub, but
that wuz impossible; fur besides the big loads uv corn an’ bacon an’
baggage the wagons hed in them, thar war from eight to a dozen
infantry men piled into them besides. Ye ort to hev heard the
quartermaster in charge uv the train tryin’ to drive the infantry men
out of the wagons and git them into the fight. I ’spect he wuz an
Irishman by his talk, fur he sed to them, ‘Git out uv thim wagons, git
out uv thim wagons; yez’ll hev me tried fur disobadience uv ordhers
fur marchin’ tin min in a wagon whin I’ve ordhers but fur ait!’”
How long I might have been detained listening to California Joe’s
recital of incidents of first campaigns, sandwiched here and there by
his peculiar but generally correct ideas of how to conduct an Indian
campaign properly, I do not know; time was limited, and I had to
remind him of the fact to induce him to shorten the conversation. It
was only deferred, however, as on every occasion thereafter
California Joe would take his place at the head of the column on the
march, and his nearest companion was made the receptacle of a
fresh instalment of Joe’s facts and opinions. His career as “chief
scout” was of the briefest nature. Everything being in readiness, the
four scouting columns, the men having removed their sabres to
prevent clanging and detection, quietly moved out of camp as soon
as it was sufficiently dark, and set out in different directions.
California Joe accompanied that detachment whose prospects
seemed best of encountering the Indians. The rest of the camp soon
afterward returned to their canvas shelter, indulging in all manner of
surmises and conjectures as to the likelihood of either or all of the
scouting parties meeting with success. As no tidings would probably
be received in camp until a late hour of the following day, taps, the
usual signal from the bugle for “lights out,” found the main camp in
almost complete darkness, with only here and there a stray
glimmering of light from the candle of some officer’s tent, who was
probably reckoning in his own mind how much he was losing or
perhaps gaining by not accompanying one of the scouting parties.
What were the chances of success to the four detachments which
had departed on this all night’s ride? Next to nothing. Still, even if no
Indians could be found, the expeditions would accomplish this much:
they would leave their fresh trails all over the country within a circuit
of twenty miles of our camp, trails which the practised eyes of the
Indians would be certain to fall upon in daylight, and inform them for
the first time that an effort was being made to disturb them if nothing
more.
Three of the scouting columns can be disposed of now by the
simple statement that they discovered no Indians, nor the remains of
any camps or lodging places indicating the recent presence of a war
party on any of the streams visited by them. The fourth detachment
was that one which California Joe had accompanied as scout. What
a feather it would be in his cap if, after the failure of the scouts
accompanying the other columns to discover Indians, the party
guided by him should pounce upon the savages, and by a handsome
fight settle a few of the old scores charged against them!
The night was passing away uninterrupted by any such event,
and but a few hours more intervened before daylight would make its
appearance. The troops had been marching constantly since leaving
camp; some were almost asleep in their saddles when the column
was halted, and word was passed along from man to man that the
advance guard had discovered signs indicating the existence of
Indians near at hand. Nothing more was necessary to dispel all
sensations of sleep, and to place every member of the command on
the alert. It was difficult to ascertain from the advance guard,
consisting of a non-commissioned officer and a few privates,
precisely what they had seen. It seemed that in the valley beyond,
into which the command was about to descend, and which could be
overlooked from the position the troops then held, something
unusual had been seen by the leading troopers just as they had
reached the crest. What this mysterious something was, or how
produced, no one could tell; it appeared simply for a moment, and
then only as a bright flash of light of varied colors; how far away it
was impossible to determine in the heavy darkness of the night. A
hasty consultation of the officers took place at the head of the
column, when it was decided that in the darkness which then reigned
it would be unwise to move to the attack of an enemy until something
more was known of the numbers and position of the foe. As the
moon would soon rise and dispel one of the obstacles to conducting
a careful attack, it was determined to hold the troops in readiness to
act upon a moment’s notice, and at the same time send a picked
party of men, under guidance of California Joe, to crawl as close to
the supposed position of the Indians as possible, and gather all the
information available. But where was California Joe all this time?
Why was he not at the front where his services would be most likely
to be in demand? Search was quietly made for him all along both
flanks of the column, but on careful inquiry it seemed that he had not
been seen for some hours, and then at a point many miles from that
at which the halt had been ordered. This was somewhat remarkable,
and admitted of no explanation—unless, perhaps, California Joe had
fallen asleep during the march and been carried away from the
column; but this theory gained no supporters. His absence at this
particular time, when his advice and services might prove so
invaluable, was regarded as most unfortunate. However, the party to
approach the Indian camp was being selected when a rifle shot
broke upon the stillness of the scene, sounding in the direction of the
mysterious appearance which had first attracted the attention of the
advanced troopers. Another moment, and the most powerful yells
and screams rose in the same direction, as if a terrible conflict was
taking place. Every carbine was advanced ready for action, each
trigger was carefully sought, no one as yet being able to divine the
cause of this sudden outcry, when in a moment who should come
charging wildly up to the column, now dimly visible by the first rays of
the moon, but California Joe, shouting and striking wildly to the right
and left as if beset by a whole tribe of warriors. Here, then, was the
solution of the mystery. Not then, but in a few hours, everything was
rendered clear. Among the other traits or peculiarities of his
character, California Joe numbered an uncontrollable fondness for
strong drink; it was his one great weakness—a weakness to which
he could only be kept from yielding by keeping all intoxicating drink
beyond his reach. It seemed, from an after development of the affair,
that the sudden elevation of California Joe, unsought and
unexpected as it was, to the position of chief scout, was rather too
much good fortune to be borne by him in a quiet or undemonstrative
manner. Such a profusion of greatness had not been thrust upon him
so often as to render him secure from being affected by his
preferment. At any rate he deemed the event deserving of
celebration—professional duties to the contrary notwithstanding—
and before proceeding on the night expedition had filled his canteen
with a bountiful supply of the worst brand of whiskey, such as is only
attainable on the frontier. He, perhaps, did not intend to indulge to
that extent which might disable him from properly performing his
duties; but in this, like many other good men whose appetites are
stronger than their resolutions, he failed in his reckoning. As the
liquor which he imbibed from time to time after leaving camp began
to produce the natural or unnatural effect, Joe’s independence
greatly increased until the only part of the expedition which he
recognized as at all important was California Joe. His mule, no
longer restrained by his hand, gradually carried him away from the
troops, until the latter were left far in the rear. This was the relative
position when the halt was ordered. California Joe, having indulged
in drink sufficiently for the time being, concluded that the next best
thing would be a smoke; nothing would be better to cheer him on his
lonely night ride. Filling his ever present brierwood with tobacco, he
next proceeded to strike a light, employing for this purpose a storm
or tempest match; it was the bright and flashing colors of this which
had so suddenly attracted the attention of the advance guard. No
sooner was his pipe lighted than the measure of his happiness was
complete, his imagination picturing him to himself, perhaps, as
leading in a grand Indian fight. His mule by this time had turned
toward the troops, and when California Joe set up his unearthly
howls, and began his imaginary charge into an Indian village, he was
carried at full speed straight to the column, where his good fortune
alone prevented him from receiving a volley before he was
recognized as not an Indian. His blood was up, and all efforts to
quiet or suppress him proved unavailing, until finally the officer in
command was forced to bind him hand and foot, and in this condition
secured him on the back of his faithful mule. In this sorry plight the
chief scout continued until the return of the troops to camp, when he
was transferred to the tender mercies of the guard as a prisoner for
misconduct. Thus ended California Joe’s career as chief scout.
Another was appointed in his stead, but we must not banish him
from our good opinion yet. As a scout, responsible only for himself,
he will reappear in these pages with a record which redounds to his
credit.
 Nothing was accomplished by the four scouting parties except,
perhaps, to inspire the troops with the idea that they were no longer
to be kept acting merely on the defensive, while the Indians, no
doubt, learned the same fact, and at the same time. The cavalry had
been lying idle, except when attacked by the Indians, for upward of a
mouth. It was reported that the war parties, which had been so
troublesome for some time, came from the direction of Medicine
Lodge creek, a stream running in the same general direction as Bluff
creek, and about two marches from the latter in a northeasterly
direction. It was on this stream—Medicine Lodge creek—that the
great peace council had been held with all the southern tribes with
whom we had been and were then at war, the Government being
represented at the council by Senators and other members of
Congress, officers high in rank in the army, and prominent gentlemen
selected from the walks of civil life. The next move, after the
unsuccessful attempt in which California Joe created the leading
sensation, was to transfer the troops across from Bluff creek to
Medicine Lodge creek, and to send scouting parties up and down the
latter in search of our enemies. This movement was made soon after
the return of the four scouting expeditions sent out from Bluff creek.
As our first day’s march was to be a short one, we did not break
camp on Bluff creek until a late hour in the morning. Soon everything
was in readiness for the march, and like a travelling village of
Bedouins, the troopers and their train of supplies stretched out into
column. First came the cavalry, moving in column of fours; next
came the immense wagon train, containing the tents, forage, rations,
and extra ammunition of the command, a very necessary but
unwieldy portion of a mounted military force. Last of all came the
rear guard, usually consisting of about one company. On this
occasion it was the company commanded by the officer whose
narrow escape from the Indians while in search of a party of his men
who had gone buffalo hunting, has been already described in this
chapter. The conduct of the Indians on this occasion proved that they
had been keeping an unseen but constant watch on everything
transpiring in or about camp. The column had scarcely straightened
itself out in commencing the march, and the rear guard had barely
crossed the limits of the deserted camp, when out from a ravine near
by dashed a war party of fully fifty well-mounted, well-armed
warriors. Their first onslaught was directed against the rear guard,
and a determined effort was made to drive them from the train, and
thus place the latter at their mercy, to be plundered of its contents.
After disposing of flankers, for the purpose of resisting any efforts
which might be made to attack the train from either flank, I rode back
to where the rear guard were engaged, to ascertain if they required
reinforcements. At the same time orders were given for the column
of troops and train to continue the march, as it was not intended that
so small a party as that attacking us should delay our march by any
vain effort on our part to ride them down, or overhaul them, when we
knew they could outstrip us if the contest was to be decided by a
race. Joining the rear guard, I had an opportunity to witness the
Indian mode of fighting in all its perfection. Surely no race of men,
not even the famous Cossacks, could display more wonderful skill in
feats of horsemanship than the Indian warrior on his native plains,
mounted on his well-trained war pony, voluntarily running the
gauntlet of his foes, drawing and receiving the fire of hundreds of
rifles, and in return sending back a perfect shower of arrows, or,
more likely still, well-directed shots from some souvenir of a peace
commission, in the shape of an improved breech-loader. The Indian
warrior is capable of assuming positions on his pony, the latter at full
speed, which no one but an Indian could maintain for a single
moment without being thrown to the ground. The pony, of course, is
perfectly trained, and seems possessed of the spirit of his rider. An
Indian’s wealth is most generally expressed by the number of his
ponies. No warrior or chief is of any importance or distinction who is
not the owner of a herd of ponies numbering from twenty to many
hundreds. He has for each special purpose a certain number of
ponies, those that are kept as pack animals being the most inferior in
quality and value; then the ordinary riding ponies used on the march
or about camp, or when visiting neighboring villages; next in
consideration is the “buffalo pony,” trained to the hunt, and only
employed when dashing into the midst of the huge buffalo herds,
when the object is either food from the flesh or clothing and shelter
for the lodges, to be made from the buffalo hide; last, or rather first,
considering its value and importance, is the “war pony,” the favorite
of the herd, fleet of foot, quick in intelligence, and full of courage. It
may be safely asserted that the first place in the heart of the warrior
is held by his faithful and obedient war pony.
Indians are extremely fond of bartering, and are not behindhand
in catching the points of a good bargain. They will sign treaties
relinquishing their lands, and agree to forsake the burial ground of
their forefathers; they will part, for due consideration, with their bow
and arrows, and their accompanying quiver, handsomely wrought in
dressed furs; their lodges even may be purchased at not an unfair
valuation, and it is not an unusual thing for a chief or warrior to offer
to exchange his wife or daughter for some article which may have
taken his fancy. This is no exaggeration; but no Indian of the plains
has ever been known to trade, sell, or barter away his favorite “war
pony.” To the warrior his battle horse is as the apple of his eye.
Neither love nor money can induce him to part with it. To see them in
battle, and to witness how the one almost becomes a part of the
other, one might well apply to the warrior the lines—

But this gallant

Had witchcraft in ’t; he grew into his seat,
And to such wondrous doing brought his horse,
As he had been encorps’d and demi-natur’d
With the brave beast; so far he passed my thought
That I, in forgery of shapes and tricks,
Come short of what he did.

The officer in command of the rear guard expressed the opinion

that he could resist successfully the attacks of the savages until a
little later, when it was seen that the latter were receiving accessions
to their strength and were becoming correspondingly bolder and
more difficult to repulse, when a second troop of cavalry was brought
from the column, as a support to the rear guard. These last were
ordered to fight on foot, their horses, in charge of every fourth
trooper, being led near the train. The men being able to fire so much
more accurately when on foot, compelled the Indians to observe
greater caution in their manner of attack. Once a warrior was seen to
dash out from the rest in the peculiar act of “circling,” which was
simply to dash along in front of the line of troopers, receiving their
fire and firing in return. Suddenly his pony, while at full speed, was
seen to fall to the ground, showing that the aim of at least one of the
soldiers had been effective. The warrior was thrown over and
beyond the pony’s head, and his capture by the cavalry seemed a
sure and easy matter to be accomplished. I saw him fall, and called
to the officer commanding the troop which had remained mounted to
gallop forward and secure the Indian. The troop advanced rapidly,
but the comrades of the fallen Indian had also witnessed his mishap,
and were rushing to his rescue. He was on his feet in a moment, and
the next moment another warrior, mounted on the fleetest of ponies,
was at his side, and with one leap the dismounted warrior placed
himself astride the pony of his companion; and thus doubly
burdened, the gallant little steed, with his no less gallant riders,
galloped lightly away, with about eighty cavalrymen, mounted on
strong domestic horses, in full cry after them. There is no doubt but
that by all the laws of chance the cavalry should have been able to
soon overhaul and capture the Indians in so unequal a race; but
whether from lack of zeal on the part of the officer commanding the
pursuit, or from the confusion created by the diversion attempted by
the remaining Indians, the pony, doubly weighted as he was,
distanced his pursuers and landed his burden in a place of safety.
Although chagrined at the failure of the pursuing party to accomplish
the capture of the Indians, I could not wholly suppress a feeling of
satisfaction, if not gladness, that for once the Indian had eluded the
white man. I need not add that any temporary tenderness of feeling
toward the two Indians was prompted by their individual daring and
the heroic display of comradeship in the successful attempt to render
assistance to a friend in need.
Without being able to delay our march, yet it required the
combined strength and resistance of two full troops of cavalry to
defend the train from the vigorous and dashing attacks of the
Indians. At last, finding that the command was not to be diverted
from its purpose, or hindered in completing its regular march, the
Indians withdrew, leaving us to proceed unmolested. These contests
with the Indians, while apparently yielding the troops no decided
advantage, were of the greatest value in view of future and more
extensive operations against the savages. Many of the men and
horses were far from being familiar with actual warfare, particularly of
this irregular character. Some of the troopers were quite
inexperienced as horsemen, and still more inexpert in the use of
their weapons, as their inaccuracy of fire when attempting to bring
down an Indian within easy range clearly proved. Their experience,
resulting from these daily contests with the red men, was to prove of
incalculable benefit, and fit them for the duties of the coming
campaign. Our march was completed to Medicine Lodge creek,
where a temporary camp was established, while scouting parties
were sent both up and down the stream as far as there was the least
probability of finding Indians. The party, consisting of three troops,
which scouted down the valley of Medicine Lodge creek, proceeded
down to the point where was located and then standing the famous
“medicine lodge,” an immense structure erected by the Indians, and
used by them as a council house, where once in each year the
various tribes of the southern plains were wont to assemble in
mysterious conclave to consult the Great Spirit as to the future, and
to offer up rude sacrifices and engage in imposing ceremonies, such
as were believed to be appeasing and satisfactory to the Indian
Deity. In the conduct of these strange and interesting incantations,
the presiding or directing personages are known among the Indians
as “medicine men.” They are the high priests of the red man’s
religion, and in their peculiar sphere are superior in influence and
authority to all others in the tribe, not excepting the head chief. No
important step is proposed or put in execution, whether relating to
war or peace, even the probable success of a contemplated hunt,
but is first submitted to the powers of divination confidently believed
to be possessed by the medicine man of the tribe. He, after a series
of enchantments, returns the answer supposed to be prompted by
the Great Spirit, as to whether the proposed step is well advised and
promises success or not. The decisions given by the medicine men
are supreme, and admit of no appeal. The medicine lodge just
referred to had been used as the place of assembly of the grand
council held between the warlike tribes and the representatives of
the Government, referred to in preceding pages. The medicine lodge
was found in a deserted but well-preserved condition. Here and
there, hanging overhead, were collected various kinds of herbs and
plants, vegetable offerings no doubt to the Great Spirit; while, in
strange contrast to these peaceful specimens of the fruits of the
earth, were trophies of the war path and the chase, the latter being
represented by the horns and dressed skins of animals killed in the
hunt, some of the skins being beautifully ornamented in the most
fantastic of styles peculiar to the Indian idea of art. Of the trophies
relating to war, the most prominent were human scalps, representing
all ages and sexes of the white race. These scalps, according to the
barbarous custom, were not composed of the entire covering of the
head, but of a small surface surrounding the crown, and usually from
three to four inches in diameter, constituting what is termed the scalp
lock. To preserve the scalp from decay, a small hoop of about double
the diameter of the scalp is prepared from a small withe, which
grows on the banks of some of the streams in the West. The scalp is
placed inside the hoop, and properly stretched by a network of
thread connecting the edges of the scalp with the circumference of
the hoop. After being properly cured, the dried fleshy portion of the
scalp is ornamented in bright colors, according to the taste of the
captor, sometimes the addition of beads of bright and varied colors
being made to heighten the effect. In other instances the hair is
dyed, either to a beautiful yellow or golden, or to crimson. Several of
these horrible evidences of past depredations upon the defenceless
inhabitants of the frontier, or overland emigrants, were brought back
by the troopers on their return from their scout. Old trails of small
parties of Indians were discovered, but none indicating the recent
presence of war parties in that valley were observable. The
command was then marched back to near its former camp on Bluff
creek, from whence, after a sojourn of three or four days, it marched
to a point on the north bank of the Arkansas river, about ten miles
below Fort Dodge, there to engage in earnest preparation and
reorganization for the winter campaign, which was soon to be
inaugurated, and in which the Seventh Cavalry was to bear so
prominent a part. We pitched our tents on the banks of the Arkansas
on the 21st of October, 1868, there to remain usefully employed until
the 12th of the following month, when we mounted our horses, bade
adieu to the luxuries of civilization, and turned our faces toward the
Wichita mountains in the endeavor to drive from their winter hiding
places the savages who had during the past summer waged such
ruthless and cruel war upon our exposed settlers on the border. How
far and in what way we were successful in this effort, will be learned
in the following chapter.
 XIV.
IN concluding to go into camp for a brief period on the banks of the
Arkansas, two important objects were in view: first, to devote the
time to refitting, reorganizing, and renovating generally that portion of
the command which was destined to continue active operations
during the inclement winter season; second, to defer our movement
against the hostile tribes until the last traces of the fall season had
disappeared, and winter in all its bitter force should be upon us. We
had crossed weapons with the Indians time and again during the
mild summer months, when the rich verdure of the valleys served as
bountiful and inexhaustible granaries in supplying forage to their
ponies, and the immense herds of buffalo and other varieties of
game roaming undisturbed over the Plains supplied all the food that
was necessary to subsist the war parties, and at the same time allow
their villages to move freely from point to point; and the experience
of both officers and men went to prove that in attempting to fight
Indians in the summer season we were yielding to them the
advantages of climate and supplies—we were meeting them on
ground of their own selection, and at a time when every natural
circumstance controlling the result of a campaign was wholly in their
favor; and as a just consequence the troops, in nearly all these
contests with the red men, had come off second best. During the
grass season nearly all Indian villages are migratory, seldom
remaining longer than a few weeks at most in any one locality,
depending entirely upon the supply of grass; when this becomes
exhausted the lodges are taken down, and the entire tribe or band
moves to some other point, chosen with reference to the supply of
grass, water, wood, and game. The distance to the new location is
usually but a few miles. During the fall, when the buffaloes are in the
best condition to furnish food, and the hides are suitable to be
dressed as robes, or to furnish covering for the lodges, the grand
annual hunts of the tribes take place, by which the supply of meat for
the winter is procured. This being done, the chiefs determine upon
the points at which the village shall be located; if the tribe is a large
one, the village is often subdivided, one portion or band remaining at
one point, other portions choosing localities within a circuit of thirty or
forty miles. Except during seasons of the most perfect peace, and
when it is the firm intention of the chiefs to remain on friendly terms
with the whites at least during the winter and early spring months,
the localities selected for their winter resorts are remote from the
military posts and frontier settlements, and the knowledge which
might lead to them carefully withheld from every white man. Even
during a moderate winter season, it is barely possible for the Indians
to obtain sufficient food for their ponies to keep the latter in anything
above a starving condition. Many of the ponies actually die from
want of forage, while the remaining ones become so weak and
attenuated that it requires several weeks of good grazing in the
spring to fit them for service—particularly such service as is required
from the war ponies. Guided by these facts, it was evident that if we
chose to avail ourselves of the assistance of so exacting and terrible
an ally as the frosts of winter—an ally who would be almost as
uninviting to friends as to foes—we might deprive our enemy of his
points of advantage, and force him to engage in a combat in which
we should do for him what he had hitherto done for us; compel him
to fight upon ground and under circumstances of our own selection.
To decide upon making a winter campaign against the Indians was
certainly in accordance with that maxim in the art of war which
directs one to do that which the enemy neither expects nor desires to
be done. At the same time it would dispel the old-fogy idea, which
was not without supporters in the army, and which was confidently
relied on by the Indians themselves, that the winter season was an
insurmountable barrier to the prosecution of a successful campaign.
But aside from the delay which was necessary to be submitted to
before the forces of winter should produce their natural but desired
effect upon our enemies, there was much to be done on our part
before we could be ready to coöperate in an offensive movement.
The Seventh Cavalry, which was to operate in one body during
the coming campaign, was a comparatively new regiment, dating its
existence as an organization from July, 1866. The officers and
companies had not served together before with much over half their
full force. A large number of fresh horses were required and
obtained; these had to be drilled. All the horses in the command
were to be newly shod, and an extra fore and hind shoe fitted to
each horse; these, with the necessary nails, were to be carried by
each trooper in the saddle pocket. It has been seen that the men
lacked accuracy in the use of their carbines. To correct this, two drills
in target practice were ordered each day. The companies were
marched separately to the ground where the targets had been
erected, and, under the supervision of the troop officers, were
practised daily in firing at targets placed one hundred, two hundred,
and three hundred yards distant. The men had been previously
informed that out of the eight hundred men composing the
command, a picked corps of sharpshooters would be selected,
numbering forty men, and made up of the forty best marksmen in the
regiment. As an incentive to induce every enlisted man, whether
non-commissioned officer or private, to strive for appointment in the
sharpshooters, it was given out from headquarters that the men so
chosen would be regarded, as they really would deserve to be, as
the elite of the command; not only regarded as such, but treated with
corresponding consideration. For example, they were to be marched
as a separate organization, independently of the column, a matter
which in itself is not so trifling as it may seem to those who have
never participated in a long and wearisome march. Then again no
guard or picket duty was to be required of the sharpshooters, which
alone was enough to encourage every trooper to excel as a
marksman. Besides these considerations, it was known that, should
we encounter the enemy, the sharpshooters would be most likely to
be assigned a post of honor, and would have superior opportunities
for acquiring distinction and rendering good service. The most
generous as well as earnest rivalry at once sprung up, not only
between the various companies, as to which should secure the
largest representation among the sharpshooters, but the rivalry
extended to individuals of the same company, each of whom
seemed desirous of the honor of being considered as “one of the
best shots.”
 To be able to determine the matter correctly, a record of every
shot fired by each man of the command, throughout a period of
upwards of one month, was carefully kept. It was surprising to
observe the marked and rapid improvement in the accuracy of aim
attained by the men generally during this period. Two drills at target
practice each day, and allowing each man an opportunity at every
drill to become familiar with the handling of his carbine, and in
judging of the distances of the different targets, worked a most
satisfactory improvement in the average accuracy of fire; so that at
the end of the period named, by taking the record of each trooper’s
target practice, I was enabled to select forty marksmen in whose
ability to bring down any warrior, whether mounted or not, who might
challenge us, as we had often been challenged before, I felt every
confidence. They were a superb body of men, and felt the greatest
pride in their distinction. A sufficient number of non-commissioned
officers, who had proven their skill as marksmen, were included in
the organization—among them, fortunately, a first sergeant, whose
expertness in the use of any firearm was well established throughout
the command. I remember having seen him, while riding at full
speed, bring down four buffaloes by four consecutive shots from his
revolver. When it is remembered that even experienced hunters are
usually compelled to fire half a dozen shots or more to secure a
single buffalo, this statement will appear the more remarkable. The
forty sharpshooters being supplied with their complement of
sergeant and corporals, and thus constituting an organization by
themselves, only lacked one important element, a suitable
commander—a leader who, aside from being a thorough soldier,
should possess traits of character which would not only enable him
to employ skilfully the superior abilities of those who were to
constitute his command, but at the same time feel that esprit de
corps which is so necessary to both officers and soldiers when
success is to be achieved. Fortunately, in my command were a
considerable number of young officers, nearly all of whom were full
of soldierly ambition, and eager to grasp any opportunity which
opened the way to honorable preferment. The difficulty was not in
finding an officer properly qualified in every way to command the
sharpshooters, but, among so many who I felt confident would
render a good account of themselves if assigned to that position, to
designate a leader par excellence. The choice fell upon Colonel
Cook, a young officer whose acquaintance the reader will remember
to have made in connection with the plucky fight he had with the
Indians near Fort Wallace the preceding summer. Colonel Cook, at
the breaking out of the rebellion, although then but a lad of sixteen
years, entered one of the New York cavalry regiments, commencing
at the foot of the ladder. He served in the cavalry arm of the service
throughout the war, participating in Sheridan’s closing battles near
Richmond, his services and gallantry resulting in his promotion to the
rank of lieutenant-colonel. While there were many of the young
officers who would have been pleased if they instead of another had
been chosen, there was no one in the command, perhaps, who did
not regard the selection as a most judicious one. Future events only
confirmed this judgment.
After everything in the way of reorganization and refitting which
might be considered as actually necessary had been ordered,
another step, bordering on the ornamental perhaps, although in itself
useful, was taken. This was what is termed in the cavalry “coloring
the horses,” which does not imply, as might be inferred from the
expression, that we actually changed the color of our horses, but
merely classified or arranged them throughout the different
squadrons and troops according to the color. Hitherto the horses had
been distributed to the various companies of the regiment
indiscriminately, regardless of color, so that in each company and
squadron horses were found of every color. For uniformity of
appearance it was decided to devote one afternoon to a general
exchange of horses. The troop commanders were assembled at
headquarters and allowed, in the order of their rank, to select the
color they preferred. This being done, every public horse in the
command was led out and placed in line: the grays collected at one
point, the bays—of which there was a great preponderance in
numbers—at another, the blacks at another, the sorrels by
themselves; then the chestnuts, the blacks, the browns; and last of
all came what were jocularly designated the “brindles,” being the
odds and ends so far as colors were concerned—roans and other
mixed colors—the junior troop commander of course becoming the
reluctant recipient of these last, valuable enough except as to color.
The exchanges having been completed, the men of each troop led
away to their respective picket or stable lines their newly-acquired
chargers. Arriving upon their company grounds, another assignment
in detail was made by the troop commanders. First, the non-
commissioned officers were permitted to select their horses in the
order of their rank; then the remaining horses were distributed
among the troopers generally, giving to the best soldiers the best
horses. It was surprising to witness what a great improvement in the
handsome appearance of the command was effected by this
measure. The change when first proposed had not been greeted
with much favor by many of the troopers who by long service and
association in times of danger had become warmly attached to their
horses; but the same reasons which had endeared the steed to the
soldier in the one instance, soon operate in the same manner to
render the new acquaintances fast friends.
Among the other measures adopted for carrying the war to our
enemy’s doors, and in a manner “fight the devil with fire,” was the
employment of Indian allies. These were to be procured from the
“reservation Indians,” tribes who, from engaging in long and
devastating wars with the whites and with other hostile bands, had
become so reduced in power as to be glad to avail themselves of the
protection and means of subsistence offered by the reservation plan.
These tribes were most generally the objects of hatred in the eyes of
their more powerful and independent neighbors of the Plains, and
the latter, when making their raids and bloody incursions upon the
white settlements of the frontiers, did not hesitate to visit their wrath
equally upon whites and reservation Indians. To these smaller tribes
it was a welcome opportunity to be permitted to ally themselves to
the forces of the Government, and endeavor to obtain that
satisfaction which acting alone they were powerless to secure. The
tribes against which we proposed to operate during the approaching
campaign had been particularly cruel and relentless in their wanton
attacks upon the Osages and Kaws, two tribes living peaceably and
contentedly on well-chosen reservations in southwestern Kansas
and the northern portion of the Indian Territory. No assistance in
fighting the hostile tribes was desired, but it was believed, and
correctly too, that in finding the enemy and in discovering the
location of his winter hiding-places, the experience and natural tact
and cunning of the Indians would be a powerful auxiliary if we could
enlist them in our cause. An officer was sent to the village of the
Osages to negotiate with the head chiefs, and was successful in his
mission, returning with a delegation consisting of the second chief in
rank of the Osage tribe, named “Little Beaver,” “Hard Rope,” the
counsellor or wise man of his people, and eleven warriors, with an
interpreter. In addition to the monthly rate of compensation which the
Government agreed to give them, they were also to be armed,
clothed, and mounted at Government expense.
Advices from General Sheridan’s headquarters, then at Fort
Hays, Kansas, were received early in November, informing us that
the time for resuming active operations was near at hand, and urging
the early completion of all preliminaries looking to that end. Fort
Dodge, on the Arkansas river, was the extreme post south in the
direction proposed to be taken by us, until the Red river should be
crossed and the northwestern posts of Texas could be reached,
which were further south than our movements would probably carry
us. To use Fort Dodge as our base of supplies, and keep open to
that point our long line of communications, would have been,
considering the character of the country and that of the enemy to be
encountered, an impracticable matter with our force. To remedy this
a temporary base was decided upon, to be established about one
hundred miles south of Fort Dodge, at some point yet to be
determined, from which we could obtain our supplies during the
winter. With this object in view an immense train, consisting of about
four hundred army wagons, was loaded with forage, rations, and
clothing, for the supply of the troops composing the expedition. A
guard composed of a few companies of infantry was detailed to
accompany the trains and to garrison the point which was to be
selected as the new base of supplies. Everything being in readiness,
the cavalry moved from its camp on the north bank of the Arkansas
on the morning of the 12th of November, and after fording the river
began its march toward the Indian Territory. That night we encamped
on Mulberry creek, where we were joined by the infantry and the
supply train. General Sully, commanding the district, here took active
command of the combined forces. Much anxiety existed in the minds
of some of the officers, remembering no doubt their late experience,
lest the Indians should attack us while on the march, when,
hampered as we should be in the protection of so large a train of
wagons, we might fare badly. The country over which we were to
march was favorable to us, as we were able to move our trains in
four parallel columns formed close together. This arrangement
shortened our flanks and rendered them less exposed to attack. The
following morning after reaching Mulberry creek the march was
resumed soon after daylight, the usual order being: the four hundred
wagons of the supply train and those belonging to the troops formed
in four equal columns; in advance of the wagons at a proper distance
rode the advance guard of cavalry; a corresponding cavalry force
formed the rear guard. The remainder of the cavalry was divided into
two equal parts, and these parts again divided into three equal
detachments; these six detachments were disposed of along the
flanks of the column, three on a side, maintaining a distance
between themselves and the train of from a quarter to half a mile,
while each of them had flanking parties thrown out opposite the train,
rendering it impossible for an enemy to appear in any direction
without timely notice being received. The infantry on beginning the
march in the morning were distributed throughout the train in such
manner that should the enemy attack, their services could be
rendered most effective. Unaccustomed, however, to field service,
particularly marching, the infantry apparently were only able to
march for a few hours in the early part of the day, when, becoming
weary, they would straggle from their companies and climb into the
covered wagons, from which there was no determined effort to rout
them. In the afternoon there would be little evidence perceptible to
the eye that infantry formed any portion of the expedition, save here
and there the butt of a musket or point of a bayonet peeping out from
under the canvas wagon-covers, or perhaps an officer of infantry
“treading alone his native heath,” or better still mounted on an Indian
pony, the result of some barter with the Indians when times were a
little more peaceable, and neither wars nor rumors of wars disturbed
the monotony of garrison life. Nothing occurred giving us any clue to
the whereabouts of Indians until we had been marching several days