Medical gynecology : a treatise on the diseases of women from the standpoint of the physician

Front matter

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Preface

The growtli of gynecology in recent times lias been phenomenal, especially in the direction of surgery. That in this respect its progress should have been remarkable is not surprising, in view of the great advances made in general surgical knowledge during that period.

It appears in medical literature that surgery has been more assiduously cultivated than medicine. This may have induced some to push the surgical treatment of diseases of women to extremes, and in some degree to neglect medicine. On the other hand, physicians, who have been overconfident in their art, may have failed occasionally to do surgery full justice. This is evidently responsible for the frequent and often illogical discussions which have been going on in the past few years regarding so-called radical and conservative practice in gynecology.

The science and art of medicine and surgery in their highest development should be above all party questions, and those who place a just estimate on both branches of the healing art, and employ them without predilection and prejudice, are the most successful and reliable. Unreasonable devotion to either medicine or surgery is wrong.

A consciousness on the part of the author of this status of gynecology is responsible for the inception and genesis of this work. How far he may be right in thinking that there is room for a new work on the medical branch of gynecology, and to what extent the requirements have been met in this volume, the members of the medical profession alone can decide.

iy MEDICAL GYNECOLOGY.

The popularity of the author's contributions to gynecological surgery in the past raises the hope that this work may meet with an equally favorable reception.

The volume is arranged in three parts :

Part I. deals with the primary differentiation of sex, development and growth during early life, and the conditions favorable to the evolution of normal organization and the attainment of a healthful puberty. This involves the discussion of heredity and environment, including care in childhood, mental and physical education and culture, together with the necessary attentions during the transition from girlhood to womanhood.

Part II. treats of the characteristics of sex, the adaptation of structure to function, the predisposition to particular diseases, and the causes of certain affections peculiar to women. Then follow all the functional and organic diseases common to the period of active functional life of woman which naturally come under the observation and care of the physician.

Part III. discusses the menopause, or the transition from active functional life toward advanced years, and then the diseases of the latter period.

The great object in the first part of this work is to consider as fully as possible the ways and means of developing vigorous organizations and maintaining healthy functional life. This necessitates attention to hygiene at all periods of life, and all that the term implies.

In discussing the treatment of diseases the author has endeavored to define, as clearly as possible, the boundary lines between medicine and surgery, and their capabilities, so that each may be thoroughly understood and employed for the relief of suffering and the saving of life.

The Author.

Table Of Contents

CHAPTER PAGE

I. — Primary Differentiation of Sex 1

II. — Secondary Differentiation of Sex 16

Chapter I. Peimaey Differeisttiation Of Sex

The union, in utero, of paternal and maternal cells forms the germ of the future being. There are elements from which the general organization is formed, and those which are detailed to form the organs of reproduction.

Each germ contains two sets of elements — the one endowed with the power to evolve a human being and designed from the first for that purpose, the other destined to develop the organs for future reproduction.

The germ of the embryo is said to contain the elements of both sexes, but almost immediately a sex is determined by certain factors assuming prominence and activity, while others remain stationary, finally to undergo atrophy.

Primary differentiation of sex is guided by the condition of the parents at the time of generation and the nature of the germ.

As animate things naturally assume the characteristics of the seed from whence they spring, the primary differentiation of sex is influenced by heredity, which, in fact, is in force to the highest degree during the development of sex, and is the chief factor in causing the primary characteristics of sex — i. e., the sexual organs. At birth the primary differentiation of sex is completed, or nearly so, and thus far the process is under the law of heredity.

I^ot only is the specific object of these organs indicated, but the ultimate sexuality is in all respects advancing to completion.

At birth the sexual organs of the female child are formed, and, with the exception of the uterus, have attained their characteristic shape and outline, but they are, of course, immature in size. The general organization has, too, certain indications of sex, although these are not well marked.

Sexual differences become more apparent as the animal rises in the zoological scale, and in the human race the reproductive organs are the last to complete their development. It is not until general bodily perfection is nearly attained that the sexual organs undergo secondary development. It is now that the general sexual characteristics of the body and mind are shown in the mysterious transformation which occurs at this period of life.

At puberty the organism, then complete, is capable of reproduction, one of the chief offices of living beings. From birth until puberty all functions save the sexual are identical in kind, if not in degree, with those performed during the time of reproductive life. When the time called puberty arrives the complex series of events denominated sexual make themselves manifest, usually in a well-recognized way, and it is then that the organs of the general system and the sexual system, though anatomically different, become functionally correlated. The functions of ovulation and menstruation are assumed. It is during the period of development that the physician has the best opportunity to render his most valuable services to the race, therefore it is in order here to consider all questions pertaining to the management of girls from childhood to puberty.

HYGIENE, CLOTHING, FOOD, AND ENVIRONMENT DURING

EARLY LIFE.

A most important and much neglected subject bearing upon this time of woman's life is that concerning her food, clothing, exercise, education, and environment generally.

To begin life well one must be born of parents who are sound in body and mind. They need not be educated, according to the popular meaning of that term. Size and vigor of brain and body are transmitted according to purely physical laws. The children of well-developed, healthy parents who may have but a limited school education often possess great mental ability, while, on the other hand, the children of great geniuses are often stupid. The brains of great men and women are often ruined by their excessive and ill-directed labor, and their children inherit this wreckage, not the original excellence. So, also, the athlete may injure his body and transmit his broken health to his children. It is not what people have been, or what they hope to be, but what they are at the time they generate, that is transmitted to their progeny. The characteristics of parents come down to their children under laws beyond control of the will.

Medical science is, to some extent, powerless in the face of heredity. Because of imperfect mental and physical health, certain men and women are unfit to procreate ; but the advice of the physician is seldom asked for on this subject, nor is it always accepted when offered.

Science demands that none but the healthy should have offspring ; but the social state ignores the demand. The laws which protect the lives and property of the present generation can only be operative for the interest of future generations ; so the best that can be done is to improve and keep in health those who are to be the parents of the coming generation.

And the multitudinous nineteenth-century resources and devices — alimentation, physical culture, change in climate, in nurses, in the possession and constant following of the physician's directions in all the undertakings of physical and mental life — often seem to me pretty nearly equal in final results to healthy parentage.

After birth and throughout childhood the influence of parents may tend to make children like themselves, or to make them better or worse than themselves, according to the kind of care and culture bestowed.

Food is the primary necessity in raising cMldren ; the character, quantity, and time of administration should each have the scrupulous attention of all those who are responsible for the welfare of children. There is only one reliable source of supply for an infant. It is the first "food for infants" used, and it has not yet been equaled by any other. It is, indeed, a sad sight to see a helpless infant cut off from the maternal supply of food and forced to depend upon stuff manufactured by those guided in their work by a formula they do not understand and hence can not imitate. If a mother, by any misfortune or physical defect, is unable to care for her own young, a nurse should, if possible, be provided. It is a great misfortune to begin life with artificial food. The poor usually do right by their infants so far as feeding them for the first year is concerned; but in this country the rich are often derelict in this respect. It is a fact that a great many wealthy mothers can not nurse their own children. Dr. George M. Beard, who had much of the real scientist in him, once asked me what proportion of educated women of the better class were able to nurse their children. I could not tell him then, but I have since made observations which show that the proportion is small — far smaller than it should be ; smaller than among the poor, who are in less favorable circumstances. Many there are who are too weak to perform that most important of duties ; some there are who will not.

It is essential to have the maternal affection well developed. The hand seldom errs, either in controlling or caressing, when guided by pure and intelligent affection. Still, affection not under the guidance of reason and intelligence often leads to grave mismanagement. Love for children, with a clear appreciation of one's duty toward them, and knowledge of the methods of caring for them, are all necessary to success.

The love of children should not be so blind and all-absorbing as to exclude justice and common sense. This leads to unwise indulgence, which is ruinous. The want of love for children leads to neglect, with consequences which, though differing from overindulgence, are equally unfavorable. The lower animals care for their young in a most rational and effective manner. They protect them with wonderful sagacity, but do not spoil them with overindulgence. They feed them in accordance with the most approved fare, guard them from danger, teach them all they have to impart, and bring them to maturity well prepared for the life they have before them. Here is to be found in a humble way the most perfect example of caring for the young. The whole process is conducted upon a plane far below that of the human family, but it is perfect as far as it goes. The highest illustration of the proper care of children is to be found in parents who have a full share of love for children which gives interest, and also a clear comprehension of how to manage them, both with regard to what they need and how to bestow it. The two extremes may be called the upper and lower boundaries of the proper training of the young. Between these all kinds of imperfections and blunderings are to be found.

In all this training and education the mother is the chief actor. Nearly all the duties devolve upon her. The father can help by his counsel and support, and when boys are nearing manhood he can help them, and from that time onward, but this is about all he can do. Occasionally a mother is found so inefhcient that the father must needs take the larger share in caring for the children ; but he usually makes poor work of it.

Overdevotion to children on the part of the mother is to be carefully guarded against. Though in a given case the children are not injured, but fortunately and wisely cared for by all this observing care, still no mother should give her whole life to her children unless she is left alone with them. In the complete household there are others who require her care and attention besides the young autocrats of the home circle.

The quantity of food given should be limited only by the wants of the child. When a child is in health the appetite is the best guide in feeding it, so far as regards quantity. Sins without number have been committed in scrimping the diet of girls in order to make them delicate, believing that to be sickly and helpless is to be ladylike. Strange it is that some women who talk the loudest about woman' s rights deny their own girls (I should say girl, as they usually have but one) the right to eat enough to satisfy hunger. Children seldom overeat unless the wicked habit of making too long an interval between meals is established. Dr. A. Jacobi says children not only eat to live, but eat to grow also.

Nutritive changes in childhood are so rapid and the demands so frequent that the quantity of food required is relatively greater than in adult life ; hence children should be fed at regular and rather frequent intervals.

Want of attention to this induces the bad habit of eating scraps between meals. If the time is not too long, children seldom ask for food in the intervals. These general statements suffice for all healthy children, and therefore special care is necessary only when in given cases there is some apparent malnutrition. When any derangement occurs in the primary processes of nutrition it is usually manifested by loss of appetite or irregularity and capriciousness in the desire for food. On the other hand, when the secondary processes — i. e., assimilation (or the appropriation of nutriment by the tissues of the body) and metabolism — are deranged, the result will appear in the character of the tissues. Examples of this are seen in children that are fat and pale-faced. They are often regarded as pictures of health by the laity, while to the physician they are simply evidences of malassimilation. Their food literally runs to fat in place of bone, nerve, and muscle. The object, then, should be, when catering for the one class, to find food that agrees with the stomach, which really means food which that particular stomach can digest. In the other class that food should be used which gives the kind of tissue most needed. In all cases it is safe to employ an abundant supply which includes both animal and vegetable food, and the variety should only be limited by the exclusion of articles which are known to be unwholesome. Finally, girls and boys should eat at the same table and fare alike. The differentiation of sex which is observed at birth should remain elementary until toward puberty, so that during childhood the nutrition of both sexes should be the same. But the food and feeding of girls about the time of puberty is a subject of much magnitude. I presuppose the fact that the general principles of dieting are known, and I shall specially consider the subject in reference to the physical culture of girls.

In the first place, I am perfectly satisfied that a mixed diet is necessary to all, that is, it should include animal and vegetable articles of food, and in quantity sufficient to satisfy the wants. There is, of course, much difference in the kind of food required by each girl. One who is healthy, actively occupied, and growing requires as much food as an adult ; many seem to want even more. They should partake of at least three good meals a day and have ample time for mastication and insalivation as well as for subsequent digestion.

It frequently happens that it is beneficial for girls to eat oftener than thrice a day, the amount in such cases being less than if the regulation number of meals were taken.

Too little attention is given in this country to the subject of food and feeding.

Eating should become an essential and pleasant duty, to be at all times enjoyed — first a duty, and then an agreeable and pleasant pastime. A young growing girl who does not enjoy her breakfast is not at all likely to enjoy her school work ; indeed, a girl should not be permitted to go to school if she has not eaten a good and sufficient breakfast. If an engineer and his locomotive should come up and report for duty in the morning without a tender, both would be sent back as unfit for the work before them. The same should apply exactly to schoolgirls. A good, nutritious, easily digested lunch should be eaten by all schoolgirls. While ambitious scholars may struggle along without proper food for a time, they are sure to break down in time. Another error is hurried eating ; this impairs the appetite and causes it to flag. Too higMy seasoned food will develop a morbid appetite, and eating such should be forbidden before digestion is completely ruined.

The question here arises as to what should be given to drink. Certainly in this country there is too much water drinking, and the unwise custom of partaking of tea, coffee, wine, mineral waters, and fancy drinks known under the generic term of soda water. This climate with its extreme summer heat is, no doubt, largely responsible for this unfortunate habit, but deranged digestion from improper feeding is also an important cause. It may be laid down as a rule that the great American drink — iced water — should not be indulged in immediately before, during, or immediately after meals. If thirst demands it, a little iced water may be slowly taken from an hour to half an hour before meals, or time enough to allow the stomach to fully recover from the chilling process, and it should not be taken again until long enough after meals to allow gastric digestion to be pretty nearly completed. Warm drinks are less objectionable, and that raises the question as to whether children should be allowed tea, coffee, cocoa, and the like. I believe that any of these may be given in small quantity when largely diluted and made agreeable. I believe it is the best way of supplying the fluid necessary to insure digestion. This, I think, is particularly essential at breakfast time in this trying climate. For luncheon at school, tea and coffee may be withheld, and the necessary fluid supplied in the form of soup or bouillon. At the evening meal most children do better without either tea or coffee ; but if a natural thirst — one not acquired by habit — demands drink, pure water, Apollinaris, Hygeia, or some of the table waters that are known to be pure may be indulged in.

All that ha,s been said on this subject applies to the healthy, strong, well-balanced organization — to those who by reason of good health are capable of digesting wholesome food and who do not require any special kind of diet because of some defect in their health or general organization.

We now come to the most important part of tliis subject, and that is the management of unhealthy girls. And first of all, because most frequently seen in this country, is the spare, nervous girl with a capricious appetite — one who seldom if ever has a good appetite for breakfast. At times such a one will eat enough, perhaps more than seems necessary, while again she declines all food. With such it is very necessary that they should have perhaps a still greater variety, always keejping within the bounds of wholesome food, and yet such, as it were, that invites them to eat. They certainly are benefited by partaking of some warm drink, like weak tea or coffee, the first thing in the morning.

I have found very weak coffee with a little lemon Juice and sugar to provoke an appetite for breakfast in very delicate individuals, and to take away the desire for drinking more coffee or anything else after eating. Should this fail to induce an appetite, let them drink a cup of good cocoa ; this is nutritious and disliked by few.

If they can partake of solid food, warm milk, eggs, and oatmeal with cream and sugar form an excellent breakfast. At times a small piece of bacon or smoked beef, well cooked and presented in a delicate way, acts as an appetizer. Should any or all of these succeed in whetting the appetite, there must nevertheless be an alternation of them from time to time, for the appetite is a nervous function and soon grows intolerant of routine.

I exclude from the diet of this class of cases hot bread, cakes, fried potatoes, sausages, and salt fish, except carefully prepared codfish balls.

It is a mooted question how much animal food girls of this temperament should partake of. Once a day is often enough, I believe.

Sweets — ice-cream and sweet desserts — are both enjoyable and profitable in these cases ; but pastry never. And I believe that food denominated "fatty" can be taken with advantage.

I have been describing the modus mvendi of that temperament wMcli modern science aptly calls ^^ sensitlf,'^^ or '■'- sensitif-actif'' — temperaments (formerly nervous) whose fancy, imagination, introspection, ambition, strong passions, and excessive sensibilities, with marked physical activity (nervous strength), are the prominent features.

The phlegmatic type of former years we now know as ^^ apathique'''' — heavy, stolid, slow, sleepy, lazy — yet, strange to say, with at times such characteristics of the '''' sensitif^ class that we may well call them ^^ sensitif-apatMque.^''

These girls require a very different diet. They should have very little farinaceous food, very little sugar, but a sufficient supply of lean meat, brown, bread, oatmeal, fruit, and the less starchy vegetables. Barley flour, which contains less starch than the average farinaceous articles of food, is of the greatest advantage to them, and can be cooked in a variety of ways, both agreeable and beneficial. A limited supply of fluids should be partaken of, whereas girls of the sensitif (nervous) type should be encouraged to the ingestion of larger quantities.

Pure air is high on the list of those conditions that may be called essential elements of growth, development, and health. This all-important factor in life and the maintenance of health, a constant supply of which we all know is mandatory, is, at least in large cities, nearly always contaminated, and yet with a little attention much of the bad air which we are obliged to breathe, as things now are, may be avoided. As our houses are built (and schoolhouses are included), the air is often very contaminated, and it is impossible, by any effort on the part of the housekeeper or teacher, to have it at all times what it should be. Great attention, however, should be given to this, and, if it is impossible to secure the requisite supply of fresh air in school, children should be kept in the open air the larger portion of their time. The sleeping rooms of growing girls can nearly always be ventilated ; and if a little attention is given to selecting schools, much can be done, and with the additional advantage, that as soon as the teachers, especially of the private and higher schools, know that the parents

PRIMARY DIFFERENTIATION OP SEX. H

and guardians insist on good ventilation, they will make efforts to secure it.

Parlors and sitting rooms should in winter be carefully ventilated, or children and young girls should be kept out of them. My idea is that after each recitation of an hour in school the children should go out for a five or ten minutes' run. More out-of-door life is necessary, and none the less so because our climate seems against it.

In connection with the subject of pure air it is, of course, needless to say that the plumbing should be perfect in all buildings.

Predisposition to disease is often transmitted, but also arises from malenvironment in early life. Impure air is said to predispose to phthisis by preventing development of lung tissue, thus giving the bacilli of tubercle a fair field to act in.

Chlorosis is in part induced by impure air and inaction of the respiratory organs in early life. And since chlorotics are prone to degenerative diseases and cancer, the effects of impure air are often far-reaching in their evil influence.

While in adult life the results of breathing impure air are visible and immediate, such is not the case to the same extent in youth. But the results are just as bad and more lasting.

Olothing has for its object the securing, as far as possible, of warmth— an equable temperature— to the body. While it is a protection, it should never retard motion. Clothing should be equally distributed over the body, and there is no reason why the chest and abdomen of a child should be covered thickly and with finery while the arms and legs are as bare as a savage's. During the transition from girlhood to womanhood marked attention is necessary, with special reference to the characteristics and peculiarities of sex. I may allude here to certain respects in which errors are most likely to occur in regard to clothing. At the present time, and probably in the past, fashion seems to be based upon capricious ideas. While it should be governed entirely by the laws of adornment, which play an important part in sexual selection of the female, it is in reality governed by perverted ideas of wliat is supposed to be beautiful and attractive. About the time when this transition takes place the usual custom is to increase the weight of skirts and to use corsets, intending thereby to beautify. This would be all perfectly right if it did not interfere with health. There is that in the mental condition of girls and mothers which prompts them to seek the robes of maturity, but it is contrary to hygiene to add additional weight to the skirts and to induce severe constriction at the waist by tight clothing, which is usually employed at this period of life. Corsets — the subject of condemnation by all reformers in dress — are still worn by women, and it is possible that they ever will be.

Their persistent use has led me to study the subject. I have come to the conclusion that this injurious article of the wardrobe is not so very bad in itself. Corsets, if properly made and worn as they ought to be, are as harmless as any portion of clothing usually worn. It is the abuse of the article that we condemn. The corset has been so long worn that there is a demand established for it, and the mammary glands of civilized women require support because the deep fascia — the natural support of these glands — is imperfectly developed, and has been so for many generations, this imperfection having been transmitted from mother to daughter through heredity. The resulting pendulous state of the breasts therefore requires artificial support, and this is best supplied by well-fitting corsets. This has been overlooked by those who would institute immediate reform, entirely abandoning this article of clothing. It would take several generations to cultivate a form and figure that would admit the disuse of corsets in mature womanhood. Take the women of our own time as they are, and it will be found that they are more comfortable and just as healthy with the proper use of corsets. The absurd and cruel habit of lacing corsets need not be alluded to, except to say that there is this great danger not generally known even to those who desire to dress rationally : that the waist will contract under very slight but long-continued pressure. The corset that is only snug to-day will be loose a week hence. The same harm can be done by wearing a tight waist. Great care should therefore be exercised in keeping corsets loose, especially in young growing women. I have also thought that if some elastic material could be introduced into the mechanism of the corset which would permit every motion of the body, at the same time giving required" support to the mammary glands and to the skirts, it would be an improvement ; in fact, I believe such a corset is now obtainable.

I do not find it possible to separate the discussion of the harm done by corset wearing about the time of puberty and that occurring to the mature woman in the active period of her life.

Tight corsets induce costal respiration, and our anatomies and physiologies calmly tell us that this is the feminine type. But a woman whose waist is nonconstricted will breathe like a healthy man.

The pelvic circulation is greatly dependent upon the free movement of the diaphragm ; hence anything tight about the lower ribs works positive harm to the sexual organs.

This is scarcely the place to adduce all the displacements of uterus, liver, stomach, kidneys, or intestines that are recorded and described as direct results of tight lacing from corsets, straps, or belts. To the anatomist they form a chamber of horrors.