Females and their diseases; a series of letters to his class

Front matter

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Letter VII

Ruptured labium — Ruptured labium and perineum — Uncured laceration of perineum with procidentia uteri — Labial cysts — Warts of the vulva — Dr. Brainerd's letter to J. F. Meigs— Pruritus of the vulva — Cicatrices, - - 6S — 79

Letter IX

Vagina — Its structure and relations — Absence of the vagina — Operation by Dr. Randolph for absence of vagina — Congenital narrowness of the vagina — Dilatation of the vagina as a cure — Imperforation or atresia — Cases — Cohesion of vaginal walls after labor — Case of the same — Ulceration of the vagina — Vaginitis — Inversion of the vagina — Vaginal fistula — Vaginal rectocele — Vaginal enterocele — Vaginal cystocelc — Double vagina, .... S3 — 112

X CONTENTS.

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Letter X

Cohesion of labia and nymphse — Ulcerated nymphse — Excision of nymphae, by Mauriceau, -------. 113 — H7

LETTER XL

Clitoris — Herraaphrodism — Free Martin — Nymphomania — Inversion of the bladder— Mr. Crosse's case, ---... H8 — 126

Letter XII

Displacements of the womb — Prolapsus uteri — Lamotte's account of it — Prolapsus, with abdominal neuralgia. — Case — Levators ani in prolapsus — Diagnosis — Carus' curve — Dr. J. H. Bennet — Causes of prolapsus — Pessaries — Gynseciorum of Spach — Simulative prolapsus — Miss Helen Blanque's case, and dialogue with her, --.-.--- 127—163

Letter XVI

Retroversion of the womb — Wood-cut of retroversion — Dr. Amussat's pamphlet — Wm. Hunter and Dr. Hall — Dialogue with a patient — Cases — 'Treatment — Chronic retroversion — Pregnancy as a cause of retroversion — Dr. Weir — Mr. Mayor's case — Instrument for the repositing of the womb, - 190 — 218

Letter XXXVII

Disorders of pregnancy — Fecundation and conception — Early changes of the womb — Uterine intrusion — Ovum grows by vis insita — A ventre plat, enfant ily a — Sympathy with uterus in the mammary glands, the stomach, &c. — Missing the return — Quickening — Rational signs and sensible signs — Some of the signs, as diseases of pregnancy — Salivations and vomitings — Bruit de souffle uterin — Sounds of foetal heart — Dr. J. A. H. De Paul, of Paris, and his work on Auscultation— Early discoveries of foetal heart — Evory Kennedy and others — (Edema gravidarum — Constipation — Compression of the great vessels by womb — Duration of gestation — Incipient phlebitis from varix, ... 472 — 500

LETTER XXXVHI.

Disorders of pregnancy continued — Cost of pregnancy to the blood-membrane — Anaemia — A case — Palpitation — Endocarditis — Dropsy of chest — Sprain of the symphyses — Dr. Moreau's case detailed, - - - - 501 — 519

Letter XXXIX

Abortion — Dr. Merriman's table of duration of pregnancy — Causes of abortion — Take care of the pregnancy ! — Hemorrhage — Prophylaxis, - - 519 — 548

Letter XL

Lying-in diseases — Fainting after delivery — Concealed hemorrhage — Turn out the clots — Binder and compress — Keep the head down — Ergot — Opium — After-pains — Rheumatismus uteri — Neuralgia of womb and abdomen — Lochia — Dr. Lee of London — Asdrubali on bandaging the accouchee< — Retention of urine — Medicines for the accouchee — Diet — Dies nondinse — Vaccination of pregnant women, ---.-_.- 548 — 575

LETTER XLL Puerperal fever, ------- 576—624

Letter I. Motives For Writing

Gentlemen: — When I took leave of you, at the close of the session of our Lectures on the last of February, I engaged to address to you a series of letters, in which I should endeavor to lay before you my views upon some of the disorders of females ; and you may remember, I on that occasion, requested each one of you to consider these letters as addressed to himself. I felt that I had not fully discharged the obligations of my professorship as relates to disquisitions upon the sexual maladies ; and explained to you that the time allowed for a course of lectures, a period of only four months, is too short to permit any one fully to describe the many diseases to which females are liable.

I had taken advantage, it is true, of every open occasion to describe the phenomena and treatment of the disorders and accidents of the various structures which it was my province to demonstrate. Still there was much incumbent on me to say, which the shortness of your sojourn here would not allow me leisure to say.

When I enjoyed the satisfaction of meeting you in the afternoons, I felt that my happiness was to be esteemed great, in the privilege of addressing so great a number of gentlemen, all patiently and politely receiving the instruction I wras able to convey upon very important points of a- business, which is related 2

18 GENERAL REMARKS ON CONDUCT.

to some of the most delicate and hazardous periods of female existence; I need not repeat the assurances I gave at parting with you, that I was filled with painful emotions in bidding you farewell, for I could not be insensible to the goodness you had so steadily manifested towards me, or to the admirable conduct of the whole class, which reflects the highest credit upon them, as demonstrative of their fine sense of what is due both to themselves and to their teachers, whom they distinguish and elevate by such consistent and admirable deportment.

To address these letters to you now, seems to be a renewal of our late delightful intercourse, and should I be permitted in the course of them to assist you, and strengthen your hands in your great mission of usefulness and benevolence, I shall be thankful to Him by whose Providence I have been allowed these now many years, to observe and contemplate the affections of which I am about to treat. Farewell. C. D. M.

Letter II. General Remarks On Conduct

The relations between the sexes are of so delicate a character, that the duties of a medical practitioner are necessarily more difficult when he comes to take charge of a patient laboring under any one of the great host of female complaints, than where he is called upon to treat the more general disorders, such as fevers, inflammations, the exanthemata, &c. So great, indeed, is the embarrassment arising from fastidiousness on the part either of the female herself, or of the practitioner, or both, that, I am persuaded, much of the ill success of treatment maybe justly traced thereto.

It is to be confessed that a very general opinion exists, as to the difficulty of effectually curing many of the diseases of women ; and it is as mortifying as it is true, that we see the cases of these disorders going the whole round of the profession, in any village, town, or city, and falling, at last, into the hands of the quack; either ending in some surprising cure, or leading the victim, by gradual lapses of health and strength, down to the grave, the last refuge of the incurable, or rather the uncured : I say uncured, for it is a very clear and well known truth, that many of these cases are, in their beginning, of light or trifling importance — cases in which the constitution takes no part in affections of tissues or organs, which, when slightly modified by disease, may long continue to be so without provoking any disturbance as to the harmony of the other great organs : this for example, in the organs of the circulation, nutrition, respiration, and innervation. Yet, by neglecting such affections in their rise, on the one hand, or by imprudently treating them by violent and disturbing therapeutical or hygienical methods on the other, the whole constitution at length comes into sympathy with the deranged member of it; and the health, the usefulness, and so, the happiness or life of the mismanaged and misinformed female, are sacrificed.

All these evils of medical practice spring not, in the main, from any want of competency in medicines, or in medical men ; but from the delicacy of the relations existing between the sexes ; and, in a good degree, from the want of information among the population in general, as to the import and meaning, and tendency of disorders, manifested by a certain train of symptoms.

It is, perhaps, best, upon the whole, that this great degree of modesty should exist even to the extent of putting a bar to researches, without which no very clear and understandable notions can be obtained of the sexual disorders. I confess I am proud to say, that, in this country generally, certainly in many parts of it, there are women who prefer to suffer the extremity of danger and pain rather than waive those scruples of delicacy which prevent their maladies from being fully explored. I say it is an evidence of the dominion of a fine morality in our society ; but, nevertheless, it is true that a greater candor on the part of the patient, and a more resolute and careful inquiry on that of the practitioner, would scarcely fail to bring to light, in their early stages, the curable maladies, which, by faults on both sides, are now misunderstood, because concealed, and, consequently, mismanaged and incurable. In fact, what is it, in the human body, that can become disordered so secretly as to elude the exploratory powers of a well educated medical man, who is allowed to make the necessary inquiries?

It is an interesting question, as to what can be done to obviate the perpetuity of such evils — evils that have existed for ages. Is there any recourse by means of which the amount of suffering endured by women affected with peculiar complaints, may be greatly lessened?

I am of opinion that the answer ought to be affirmative ; for I believe, that if a medical practitioner know how to obtain the entire confidence of the class of persons who habitually consult him; if he be endowed with a clear perceptive power, a sound judgment, a real probity, and a proper degree of intelligence, and a familiarity with the doctrines of a good medical school, he will, as far as to the extent of his particular sphere of action, be found capable of greatly lessening the evils of which complaint is here made; and if these qualities are generally attached to. physicians, then it is in their power to abate the evil throughout the population in general.

Can there exist any reasonable doubt that the country is abundantly supplied with well informed physicians ; seeing that the land is filled with members of the profession, who have enjoyed the best possible opportunities of storing the mind with all the lines and precepts of medicine, delivered down through a succession of ages, continually productive of ameliorations in the doctrines and the arts of curing disease? But such persons as these are worthy of the public confidence, both as to their morals and their understanding. They are, in general, worthy representatives of the style and character of the gentleman, and, therefore, capable of attracting the confidence of such as are under suffering.

I have met to-day, April 9th, 1847, with a case which shows how far the fastidious delicacy existing in the relation betwixt the sexes may be carried to the part of the physician. A lady, 40 years of age, consulted me as to a painful menstruation she has had for twenty years. She experiences severe pain and disagreeable weight and pressure in the loins and hypogaster, and pain in the head for five or six entire days before each menstrual period ; all which symptoms disappear with the first gushings of the evacuation. She represents her health to be the same now as for twenty years past. Hence, I presume, there has occurred but little change in the physical condition of the parts, else there would be some change in the sensations arising from the malady.

She has been repeatedly subjected to the taxis ; but no one ever examined the os uteri with the speculum until to-day. Well, that examination reveals a certain state of the cervix and os uteri, and glands of Naboth, &c, which it was indispensable to know, in order to found a rational treatment. The delicacy existed, not on the part of the lady, but on that of the medical advisers; for I have her assurance, that her sufferings, both bodily and mental, have been so great, that she should long ago have submitted to any means of even a probable cure ; and was, indeed, always desirous to have everything done that was possible in her behalf. I doubt not this lady might have been cured long ago, had her malady been thoroughly understood.

I have mentioned this case to show that the physician is in fault when he does not do his whole duty; for it is incumbent on him to leave nothing undone that may aid and comfort his patient. But let us return to our remarks upon the qualities that ought to distinguish the medical man.

I think that, in order to be a physician, one ought to enjoy strong perceptive faculties ; he should be able to make nice discriminations ; quickly perceiving the slightest shades of difference in all material forms, superficies, colours, weights, and resistance. The faculty of judging between the relations and differences of things should be of the primest quality; not sudden, hasty, and impatient in its operations, but slow, dispassionate, and attentive.

The mind and heart of the practitioner ought to be the shrine of truth and probity ; his mind should not deceive itself, and his heart should not suffer itself to be deceived and misled, by any earthly temptation, from the narrow and rugged way of duty and conscientiousness.

His intelligence ought to be vast, as acquainted, very generally, with what is called knowledge and science by mankind. Particularly should he be fully informed as to the nature of the Life-force, as displayed in the various tissues and organs of any animal economy ; not in that of man alone, but in the whole zoological series, as well as in the vegetable kingdom of nature.

There ought to be no function of the economy, or of its parts, whose healthy rate he could not estimate, as well as all its deviations in sickness. But this is not all — he ought to be able to discern, not the signs only of maladies, but the tendencies of these maladies; as whether they possess a certain tendency towards recovery, or a tendency towards destruction; so as to enable him to say, as he does of a vaccine inoculation, let it alone, it requires no remedy, it carries the cure in its own nature, it will have disappeared, with all its phenomena, on the eighteenth day. Or, on the other hand, take care of that headache ; she is pregnant, and near term; know that such a headache is but a step removed from an eclampsia; and that an eclampsia is often the penultimate phenomenon of life. Let that case alone — cure this one.

Do you not perceive, young gentlemen, that such a physician is not of necessity a doser, a druggist ; and that in a great moiety of the cases in which he is consulted, the patient will escape all physic and be cured by wise counsel — and likewise, that when therapeutical interference is required, he will know what to do, what medicines are required, and when, and how much ?

It is often dangerous to ask a physician the question, what shall we do? because habit, custom, routinism, almost always compel him to say take — take.

He ought to be familiar with the doctrines of a good Medical School ; by which I mean, not the doctrines of the University of Pennsylvania, or that of New York, or Maryland, or London, or Paris, nor the Jefferson College, but a school which has taught him a demonstrative anatomy, a real eclectic physiology, a sound and philosophical chemistry, &c. A school, in short, which has set before him, in full array, the results of man's achievements in medical investigation, experience, and art; leaving him, out of his own clear, sound, honest, and capacious intellect, to become capable of saying, as to any case of disorder presented for his opinion, such is the malady, its tendencies are thus, or so, its treatment requires such and such methods. Let him judge the case by the case, and by no other law or evidence.

Let him not be a methodist — let him be a man of principles in medicine ; principles, which, like the genii of the Persian fable, come at his bidding and do his bidding, for no one can be taught to cure diseases by a method. Method in medicine is beneath contempt; because, owing to the infinite variety and differences existing among the living molecules that are the subjects of the vital forces, there never were, nor can be, two absolutely similar cases. Each instance is an integer, and should, in strictness, be so deemed, and studied, and understood, and managed upon a reference to it, and not to another integer. It is true that the patient who is under care to-day, may be like "him who died o' Wednesday," but is not him. Hence, you perceive that I am no admirer of statistics except for the government, where statistical returns of agriculture, commerce, manufactures, crime, population, &c, are useful to the statesman for making his assessments, his calculations, and his levies ; but when I treat a case of pleurisy, I do not care how you treated your case of pleurisy ; I shall bleed my patient on account of his fever, pain, cough, dyspnoea, &c, and not because you bled your patient, who had similar symptoms, of the gravity of which I am no judge, not having been present to judge. So, if I treat a female with certain pain about the middle of the sacral bone, with dysuria, or retention of urine, &c, by methods calculated to take the strain off from her ligamenta rotunda, and thus cure her of retroyersio uteri, what is it to me that you adopted some other mode ? That which interests me is, to be sure that a woman, who has ligamenta rotunda not more than two inches and a half long, cannot have her womb turned topsy-turvy. That is the principle which I ought to apprehend, and I shall carry it out in my practice. Do you get some other principle, if you can, and come to prove my error by your statistics ; I should be strongly inclined to take after Mr. Dennis Bulgruddery, in the play, who, if bothered with statistics by his friend Bull, would have been sure to say, " To the divil I pitch you and your statistics, Mr. Bull !"

Let a man, therefore, make himself so thoroughly learned in medicine that he can detect the lesion of structure or function wherever it may hide, and then he is the sole judge of the action required in the case. Not because twenty other cases were, but because this case is.

But I stated that one great cause of unsuccess, is in the absence of information among the population generally. This absence of information is the fruitful source of Homoeopathy, Hydropathy, Thompsonianism, Panaceaism, and all the Catholicons, Infallible worm destroying lozenges, Balms of Gilead, and that shocking absurdity — the Vegetable pill, which, like a sort of epidemic diarrhoea, has tormented the intestinal canal of thousands and tens of thousands of our far-seeing compatriots, until the American population have become hardened in. purgations. If Horace were here, he would not think the dura messorum ilia the toughest things in creation.

Do you suppose, my dear young gentlemen, that if the community at large should be as well acquainted with physiology and therapeutics as you and I, the Ledger and the Gazette would occupy nearly one-half of their columns with those horrid descriptions and unblushing confessions of piles and itch, and other dreadful disorders, which the sufferers under them love to parade for the public gratification and improvement, under their own signs manual in the Gazette?

You, who know the skeleton humanum, and the attitude of the uterus within the pelvis, do you think that Mrs. A. to X. would, out of a missionary zeal, suffer her name to appear as one of the wonder- worked cures of a shameless procidentia, by what is, at our daily breakfast-table, brought up in the morning paper, to stare the ladies out of countenance, under the modest title of a utero-abdominal supporter. Who wants to know, or ought to know that the ladies have abdomens and wombs but us doctors ? When I was young a woman had no legs even, but only feet, and possibly ankles; now, forsooth, they have w^ero-abdominal supporters, not in fact only, but in the very newspapers. They are, surely, not fit subjects for newspaper advertisements, nor would they be advertised but out of our own stupidity or remissness.

I say, confidently, out of our remissness, and here are my reasons for saying so.

This is a land and an age of common schools and common sense. This is a country of general knowledge among the population. It is impossible that any system of science or art can stand in this country, flooded as it is with intellectual light, sustained by any but real claims to the respect and confidence of the public. We doctors claim this confidence and respect ; and we deserve it, doubtless ; but we claim it imperiously and as a vested right, as a right descended to us by inheritance, from our avos et proavos, the founders of our order. But we ought to remember that our privileges, those we received in a commission proceeding from the Legislature, under the Great Seal of the Commonwealth, are not of the nature of the privilegium clericale, as the lawyers term it. There are too many persons in this country that can read and write, to allow us to claim a clergyable exemption from the general practice here of explaining one's self. What is the right, therefore, by which we assume, in the present day, to clothe all our proceedings in mystery, and to expect our patients to kneel down while we, (not confess, but) cut them with bistouries and knives, or put arsenic and prussic acid down their gullets ? They will not submit to our clerical manners ; and they say, that if we persist to hide our art under an impenetrable veil of mystery and jargon, they must continue incapable of discriminating betwixt the true physician and the quack-salver, since both agree upon one course, that of demanding an implicit faith and obedience without recourse to reasoning. Is not this representation a fair one ? Even your early and noviciate experience must, wTe think, have furnished you the materials for judging whether I speak fairly or not.

I say then, it is our stupidity and remissness that work evil to the people, and redound to our own hurt also; for there is no person, endowed with a good share of common sense, to whom you could not address, through that common sense, a reasonable and plain statement of the facts of his case, the probabilities as to its course, duration, and end ; with an enumeration of the safest, most convenient, and certain processes for its cure. Imagine such a person, well-informed, and you have the idea of a patient the most docile, the most exact in therapeutic and hygienic obedience; the most confiding in your skill, and the most grateful for your intervention in his behalf. Would that all our brethren in this land might adopt views like these. With their united force of intellect, of character, of beneficence, and of social station, it would be but a short time e'er the diminished head of charlatanism, under whatever disguise, would be found only to lift itself up among the most ignorant and abject portions of the population, instead of riding, as it does to-day, with chariots and with horsemen, a shame to the intelligence of the age, and a perpetual eye-sore to the lover of truth, and contemner of every species of imposture. Let us explain ourselves then to the people.

I hope it will not be deemed impertinent in me to say to you, that I have enjoyed a large share of professional business for some years past, and that, in the main, I have had reason to suppose I received very unbounded confidence, and a general obedience to my medical directions, from those persons and families who called me. This good fortune I have long attributed, in a considerable measure, to the entire frankness of my explanations as to any diagnostic, prognostic, therapeutic, and hygienic views in my cases; as well as the pathology of them.

Some of the brethren, chiefly, I presume, those who have not very clear and concise views of their own on medical topics, are bitterly opposed to all explanation, on the ground that our principles of science are too recondite for the vulgar to be able to appreciate either them or the facts on which they rest. I have occasionally met with difficulties, in consultation, from the opposition of some of the brethren to my desire- to let the patient fully into my opinions. If a man really have any opinions, that are honest and clear, and well founded, why should he conceal them ? I confess my belief, that where a physician forms perfectly transparent views of his cases, there is no need for the powdered wig and the gold-headed cane, the mysterious nod, and all the apparatus of deception that we might look for rather in old Felix Plater, or Horace Augenius, than in a modern physician, who is, or ought to be, a modern gentleman and man of honor ; and, as such, above all false pretences — open, candid, and manly.

Now, I sincerely believe, that where you desire to effect a cure, and you meet with obstruction through the timidity, the doubts, or apprehensions of the patient, you will only have to speak common sense, and to take out your pencil, and, on a sheet of paper, make a few well sketched diagrams of parts, organs, and relations of parts and organs, in order to bring the recusant back to a truer and firmer faith than before, by convincing his judgment and winning his inclination. Yea, verily, you shall sustain the fainting hope and the dying faith of the sick girl, for days and for weeks, and through months of pain, if you speak the truth and explain the truth ; if you show the hope and have the hope ; if you explain the power and really possess it.

If you have not the confidence of your patients, it is because you either do not merit it by your science, your skill, and your temper; or because possessing all these, you are destitute of, what I beg you to excuse me for calling in a grave book by a slight term, gumption. Depend upon it, my dear young gentlemen, there are plenty of people, "plenty as blackberries," who are very learned and very shining, except when you come to rub them, and who lose all shining quality, because they have not and cannot take a real polish.

The celebrated Dr. Clarke, of London, from whose lectures that capital little midwifery book, called the London Practice of Midwifery, was pirated, says, somewhere in its pages, that one Doctor, by his good sense, shall retain the entire confidence of the woman in labor through the most painful protractedness, while another would lose her confidence, in a very short time, of hope deferred; and that, not because he hath not ability as a prescriber equal to the other, but from some fault of manner, expression, or conversation.

If you would be learned men, it is well; but it is better to be wise men. A man may be wise without being learned ; but it is not uncommon to be learned, and yet to be a perfect ass in all that relates to what I might term administration, or action. Let your light, therefore, shine among men, and do not conceal it under a bushel of gawkeyness ; or some stupid conceit of your personal dignity; or, what is still more asinine, the dignity of your calling. Dignity is you, not physic, nor the practice thereof. Did you never hear that

" Worth makes the man, the want of it the fellow, And all the rest is leather and prunella?"

I have seen dignified shoemakers, carters, butchers, and even a very dignified tailor, and I have known philosophers and very learned men without dignity. Believe me, there is true dignity in great virtue, great information, and great power to diffuse, apply, and make that information useful to our fellow men. Such is the dignity you should strive to attain.

If I could give you the best piece of advice in my power, I think I should give you this advice; namely, in all your dealings with mankind as physicians, and in all your life-doings, strive, first, to increase the boundaries of your knowledge ; and, second, strive to make that knowledge as vulgar, as popular as possible. Be a reformer in this particular, and you will, should you succeed, become the real founder of a Sect in medicine, and that sect you may baptize as the Young Physic that Dr. Forbes advocates. That will be the true young physic, which succeeds in bringing down Old Physic to the level of this common sense age.

I say again, therefore, wherever you place yourself, be sure to have no concealment, no mystery, no pretence ; but endeavor, in the clearest manner, not to assert, but to show vour claims to superior powers in that great utilitarian avo cation of curing the sick and the wounded ; an avocation which is almost, I say it with reverence, next in goodness to the mission of Christ, who went about clothed with power and authority, — sysipsiv *ov$ vsxpovs