THE ABUSE OF UTERINE TREATMENT THROUGH MISTAKEN DIAGNOSIS. BY WILLIAM GOODELL, M. D., PROFESSOR OF GYNECOLOGY IN THE UNIVERSITY OF PENNSYLVANIA FROM THE MEDICAL NEWS December 7, 1889. [Reprinted from The Medical News, December 7, 1889.] THE ABUSE OF UTERINE TREATMENTTHROUGH MISTAKEN DIAGNOSIS. By WILLIAM GOODELL, M.D., PROFESSOR OF GYNECOLOGY IN THE UNIVERSITY OF PENNSYLVANIA. While the treatment of uterine diseases received a great impulse from the writings of Simpson in England, of Kiwisch and Scanzoni in Germany, and of Huguier and Recamier in France, it is to Bennet that we chiefly owe the common use of local appli- cations and the popularization of the speculum. The former gynecologists wrote about the more strictly surgical diseases of women, which were, and will ever be, relegated to specialists. But Bennet as early as 1843 'n French, and 1845 in English, published his work on Infla.7nmation of the Uterus, of which the last edition was issued in 1861. In it he contended that inflammation of the cervi- cal canal is the main factor in female diseases; that from it come ulceration, displacement, leu- corrhoea, menstrual derangement, and ovarian dis- order ; and that the inflammation, being limited to the cervical canal, can readily be dislodged by strong caustics. Written with dogmatic zeal, advis- ing a definite treatment to a reachable and a seeable object—a treatment which the humblest yeoman of 2 GOO DELL, the profession could carry out—few books of modern times have exerted so great and so widespread an influence. That riddle of the Sphinx—the cause of woman’s ill-health—had been read and interpreted ! The profession was taken fairly by storm ; the effect was as electric as the appeal of Maria Theresa to Hungarian nobles. From Arctic to Antarctic oceans, from the Mississippi to the Volga, countless specu- lums of varied form leaped from their bags and flashed in sunlight boreal, tropical, and meridional. Cauteries actual or potential, applied to actual or potential uterine sores, became the order, in fact, the ruling passion of the day. In the general en- thusiasm it was soon forgotten that every mucous membrane secretes, and that it must of course give evidence of its own secretion, just as every nose contains iis mucus. Hence, every examined womb, being found to contain mucus, was, as it were, in- valided—that is to say, it was put on the speculum list. Naturally, then, not a womb being found healthy from the speculum standpoint, this much- abused organ was charged with being the cause of almost all the ills that female flesh is heir to, and it was treated—that is to say, maltreated—for every imaginable disorder that could not be referred off- hand to some other organ. Bennet, the medical Frankenstein, had evoked a monster which could not be curbed, and for five and thirty years the speculum ran riot. But in this age of unrestful progress, at every turn of the hour-glass of time, some cherished creed, some accepted dogma, is proved a heresy, and Ben- ABUSE OF UTERINE TREATMENT. 3 net’s cervical theory fared but little better. A whole- some reaction set in. As experience grew, it was found that pelvic inflammations and strictures of the cer- vical canal came from this treatment. This discov- ery led to the abandonment of the more heroic caustics. Then, again, it gradually dawned upon truth-seekers that far more than inflammation, pas- sive congestion of the womb and of its annexes, together with resulting structural changes, that uter- ine displacements and injuries, and that ovarian and tubal lesions played important roles in the fe- male economy. In keeping with this knowledge is the far more rational and beneficial treatment of the present day. Still, granting that the treatment of actual, visible, and tangible uterine disease leaves little for improve- ment, the whole truth has not been reached—for truth evolves slowly and does not, like Aaron’s rod, bud and blossom in a night. The ball-and-chain of tradition still drags at the heel of this branch of science, and the medical mind, in close touch here with the lay mind, tends to give the reproductive organs undue importance—to attribute, in fact, al- together too much to their influence. By a very large number of practitioners, even by specialists working in other fields of medicine, these organs are too often wrongfully made the scape-goat for headaches and nape-aches, for spine-aches and back- aches, for weakness of vision, for aural disturbances, for sore-throat and weak lungs, for irritable heart, and also for a host of so-called uterine symptoms. Yet these very symptoms may be due wholly to 4 GOODELL, nerve-exhaustion, or malnutrition of nerve-centres, and not to reflex action, or to direct action, from some real or some supposed uterine disorder. I say this advisedly, because I too have thus erred, and because hardly a day passes without my seeing cases of sup- posed uterine disease which have been so treated for months—even for years—when the whole trou- ble, or the most of it, lies—not in the reproductive organs, but—in the nerve-ganglia. This abuse of uterine treatment, through a mistaken diagnosis, is, in my opinion, the great medical error of the day. Once I was asked by a medical friend to see an exceedingly bad and acute case of pruritus vulvse. Very naturally attributing it to uterine disease, he discovered a small cervical tear, and I was called to decide the question of repairing it. I, too, was, at first, led astray, but the suddenness of the seizure and the lack of consistency in the behavior of the symptoms, put me on my guard, and we soon found out the cause to be an acute attack of jealousy. To this day a lady rallies me upon a wild-goose chase which I made after a uterine cause for her neu- rasthenic symptoms. Carefully overhauling her pelvic organs I discovered nothing but a torn perineum, and attributing to that lesion all her ills, which were legion, I restored it, making at the same time the rash but honest promise of her complete restoration to health. The rent was a bad one and needed repair, but it had existed for years without doing harm, and it had nothing to do with her symptoms, although they were largely uterine in expression, notably a bearing-down feeling. They became, in ABUSE OF UTERINE TREATMENT. 5 fact, worse after the operation than before, and it was only after recognizing the nerve element of her disease, that I was enabled to do her any good. Many such mistakes, of attributing too much to the reproductive apparatus, have I seen in the practice of other physicians; but my own blunders in the same direction have made me feel very charitable toward them. Out of many examples let me give a few: Not many years ago I was asked by one of our best and most conscientious physicians, himself a gynecologist and a medical teacher, to see a very delicate and refined lady. She had passed through most of the trials which beset a clergyman’s wife, and had borne two children, the younger one ten years before. Having for many years enjoyed fairly good health, she lately had suffered a great bereavement, and she was now prostrated by nerve- exhaustion. Her symptoms were markedly of a uterine character. These were pain in the back, an irritable bladder, a pelvic bearing-down, an inability to walk, aches in the left groin, menorrhagia and leucorrhcea. These uterine symptoms had led my friend astray, and finding an insignificant cervical tear, he attributed to it all his patient’s ill-health, and, against my advice, operated upon it. The wound healed perfectly, excepting in one suture track on one side of the cervix, where a small fistula remained. His patient becoming none the better, but rather the worse, he laid the blame on this fistula, and tried to close it. Not succeeding, he again called me in. Now, this small fistula had no more to do with 6 GOO DELL, the lady’s general ill-health than the earring holes in her ears, and her disease was clearly a neurosis. Yet I could not bring my friend to my way of thinking—the uterine symptoms were too much for him, and he tinkered away at the fistula until it finally healed up, but the lady became no better. Finally, he adopted my theory of neurosis, put his patient upon an appropriate treatment, cured her, and then had the manliness to thank me for my advice. My friend is now, alas ! no more, else I would not have told this story; and I have done so simply to show how hard it is for a bright and pro- gressive mind, even for a gynecologist and a medical teacher at that, to free himself from the bias of tradition. By breaking down the nervous system, the brain- cramming, the intellectual rivalry, the buckram proprieties, and the unwholesome confinement of our boarding-schools and public schools, breed a host of sickly girls, who swarm in every class of society. Manifold diseases, both functional and structural, date from the recitation room. They are mostly of a uterine complexion, for at that time of life the sexual sphere dominates, and the brunt of the nervous and of the vascular disturbances which form the essence of nerve-exhaustion, falls on the most exacting organs—the reproductive. Hence these suffer from neuralgic pains or from congestion and the lesions coming from prolonged congestion. Yet physicians, misled by the urgency and the number of the so-called uterine symptoms, mistake the effect, or more often the counterfeited effect, ABUSE OF UTERINE TREATMENT. 7 for the cause, and give a local treatment when it should be a constitutional one. So common is it for girls in boarding-schools to suffer either from amenorrhoea or from irregular menstruation, as to create a general impression in the community that in these schools some drug -is secretly given in the food in order to lessen the laundry work. In one school of great repute so many girls missed their monthly periods that the family physician of several of them wrote to me, asking whether it were possible, as his patients averred, “ that as their clothes were laundried in the build- ing, something was given in their food or their drink to produce the effect, for the purpose of sav- ing the laundress the disagreeable task of washing the napkins.” My reply was, that if laundresses were acquainted with a drug that could arrest men- struation, they knew more than the profession ; and that his patients had lost their monthly periods, not from secret drugs, but from loss of health due to an unwholesome system of education. Another physician, the worthy chairman of a school-board in a young city, became awakened to the fact that a great proportion of the girls in the public schools were failing in health from backache, wakefulness, weariness, and disordered menstruation. Full of philanthropic and architectural zeal, and with the uterine idea firmly implanted in his head, he wrote to me, asking whether the long flights of stairs in the school-houses were not to blame for these female ailments. I replied in words to the effect that were a higher culture literal, being perched 8 GOO DELL, upon the top of some Eiffel’s tower, like Simeon Stylites upon his pillar, and were girls obliged to climb up to it, the muscular effort would no doubt put them out of breath, and repeated intellectual excursions in the same direction might in the end cause—not uterine diseases, but—the heart diseases of athletes and of Alpine climbers. I further con- tended that stair-climbingyVr.n? could rarely produce uterine disorders, and that the girls in his school were suffering—not from uterine disease, but—from the nerve-counterfeits of uterine disease, viz., from the reflexes of a nerve-exhaustion resulting from an unhealthy, and therefore faulty, system of education. My arguments evidently failed to convince this hon- est gentleman, for the correspondence abruptly ended at this point, and I have a shrewd suspicion that he carried out his architectural plans. Should any of my readers journey westward, and see in some grow- ing city a girls’ school-house fashioned like a cov- ered rope-walk or a skating-rink, depend upon it, it will turn out to be the philanthropic but mistaken evolution of my correspondent. The traveller would no doubt find education very effectively taught on the only floor—the ground floor—of this building; but doubtless, also, he would see as many pale faces, and would discover on inquiry no fewer backaches, spine-aches, womb-aches,and menstrual disturbances, than when the recitation rooms were on the third or the fourth floor. In a parous neurasthenic woman, a leucorrhoea, a slight prolapse of the womb, a small tear of the cervix, or an insignificant rent of the perineum, each plays ABUSE OF UTERINE TREATMENT. 9 the part of the will-o’-the-wisp to allure the physician away from the bottom factor. To these trifling lesions —because they are visible, palpable, and ponderable, and because he has, by education and by tradition, a uterine bias—he attributes all his patient’s trou- bles ; whereas a greater and a subtler force, the invisible, impalpable, and imponderable nervous system, may be the sole delinquent. She may be a bereaved mother, a grieving widow, or a neglected wife, and all her uterine symptoms, yes, every one of them, may be the outcome of her sorrows, and not of her local lesions. Often the victim of this misdirected treatment is a young unmarried girl, whose nerves have been upset by some secret grief, perhaps a cross in love, or by ambitious over-study. Misleading symptoms now set in, which I cannot better describe than by a quotation from one of my own articles on the subject (Lessons in Gynecology, third edition, p. 523): “ She loses her appetite, lies awake at night, and grows pale and weak. She has cold feet and blue fin- ger-nails, and perhaps complains of infra-mammary and ovarian pains. Headache and backache, spine- ache, and an oppressive sense of exhaustion distress her. Her monthly periods, hitherto without suffering, now begin to annoy her more and more, until they become extremely painful, and at these times dark circles appear under her eyes. Her linen is stained by a leucorrhcea, and bladder troubles soon set in. She is wearied beyond measure by the slightest mental or physical exertion ; the short visit of a friend upsets her for the rest of the day; ‘ a grass- 10 GOODELL, hopper is a burden ’ to her, and she finally becomes very nervous or hysterical. Now, very unfor- tunately, the idea attached to this group of symp- toms is that the womb is at fault. A moral rape is, therefore, committed by a digital or a speculum ex- amination, and two supposed lesions will be found —first, as a matter of course, the natural virginal anteflexion ; and, secondly, a slight uterine catarrh. These are at once seized upon as the prime factors, and she is accordingly subjected to a painfu', an unnerving, and a humiliating treatment for the false flexion and the sham endometritis. Unimproved, she drags herself from one consulting room to another, until finally, in despair, she settles down to a sofa in a darkened room, and becomes either the spoiled pet or the vampire of the family.” That this is not an over-wrought picture, every one of my readers will attest. For what physician has not had the original as a patient, and cursed his stars for the possession ? At the present time there are in my private hos- pital seven ladies who are rapidly recovering from general nerve-exhaustion and from its sham uterine symptoms. They will get well without any local treatment whatever. Yet all were pronounced by their physicians to be cases of uterine disease, and had been so treated for months, and even for years, without benefit. One of them was urged by an ex- cellent authority to submit to the removal of her ovaries; another, to have her slightly torn cervix sewn up; a third, to have a trifling rent in the perineum repaired. Whilst the fourth, a young girl whose nerves have given way from hard study, ABUSE OF UTERINE TREATMENT. 11 had a perfectly healthy and a perfectly poised womb, propped up by an anteflexion pessary, treated every other day, for weeks, by an application, and de- luged twice a day with gallons of hot water. Many of us have laughed at the quaint but kind doctor in one of Bulwer’s novels, who prescribes a special pellet for each emotion, and calms a passion by its appropriate parvule. But are we, the phy- sicians of the nineteenth century, a century of in- finite progress, are we, I say, a whit the wiser? We who seek to cure the nerve-reflexes of grief, of love, of neglect and of jealousy, not by harmless infinitesi- mals, but by the removal of the ovaries, and by operations upon the cervix and the perineum ; or try to salve brain-wounds and heart-pangs by ante- flexion pessaries, by uterine applications and by vaginal douches of a temperature of no°? Can the rankest materialism be pushed further than this? Fortunately for the reputation of my professional brothers, and fortunately for my own—for I, the heavy Mentor of this homily, have also sinned and in like manner—this grave error of diagnosis is not without excuse. The symptoms of nerve-prostration so greatly resemble those of eveft coarse uterine lesions that the nerve-mimicries can very readily be mistaken for signals of actual organic disease. Nor, indeed, are they always distinguishable the one from the other, for the marvellous kinship be- tween mind and matter is a tangled skein, not yet unravelled by dead-house or by laboratory. What, then, are these symptoms? Their name is legion, but the most common ones are, strangely 12 GOODELL, enough, those which lay and professional tradition, with singular consent, have labelled as the symp- toms par excellence of womb disease. They are, in the order of their frequency, great weariness, more or less of nervousness and of wakefulness; inability to walk any distance and a bearing-down feeling ; headache, rape-ache and backache; cold feet, an irritable bladder, spinal tenderness and pain in one ovary, usually the left, or in both ovaries. The sense of exhaustion is a remarkable one : the woman is always tired ; she passes the day tired, she goes to bed tired, and she wakes up tired, often, indeed, more tired than when she fell asleep. She sighs a great deal, and her arms and legs tremble or “fall asleep ’ ’ so frequently that she fears palsy or paralysis. Other symptoms not quite so common are the cerebral ones: such as low spirits, bad dreams, nightmares and night-terrors; explosive sounds in the head, a loss of memory, suicidal thoughts, the fear of impending insanity, the dread of being left alone or of being in a crowd. Some patients are unable to protrude the tongue, or they may have weakness of vision, or a morbid keenness of smell or of taste. Otliers are kept away from church on account of spinal thrills and locking of the jaws, whenever they hear the lower or the tremulous notes of the organ. The uterine reflexes are: uterine, pelvic and ovarian aches; pendulum pains swinging from one groin to the other, jerking muscles which can- not keep still, a trembling or a quivering in the abdomen, or a feeling that it needs support, which ABUSE OF UTERINE TREATMENT. 13 is often given by pressure with the hands. The in- testines display their interest in the general neu- rosis, by flatulence, by noisy borborygmi, and by the belching of wind in large volumes. They usually keep bound, but sometimes they are loose, or the two conditions alternate. One very common symptom is great exhaustion after a movement of the bowels, and these movements are often caused at unseasonable hours by any simple excitement, such as the ring of the door-bell or the call of a friend. Dyspeptic symptoms are rarely absent, sometimes they are very marked, while the tongue looks per- fectly clean, even when nausea, vomiting, or diar- rhoea are present. Some nervous women are annoyed by clammy hands and feet, or by profuse sweats, which often are not general, but either local or unilateral. Thus I have seen one-half of the face always wet, while the other half kept dry. One of my pa- tients perspired so profusely from the tips of her fingers, that they were constantly dripping and she could not wear gloves. Once I saw a hysteri- cal nose;[distilling a clear serum, which for weeks dribbled away, almost in a stream. The annoyance was great, yet no treatment whatever did the slight- est good; but one day it vanished as mysteriously as it came. Many nervous women are frightened by muscular cramps, or by tinglings, by loss of sen- sation, or by numbness in the extremities, which are deemed the precursors of paralysis. Nor does the skin escape the general sympathy. It becomes dry, 14 GOODELL, harsh and scurfy, and pigmentary deposits appear under the eyes, around the nipples, and on the chin and forehead. Blondes are likely to get a mottled complexion, and brunettes may become disfigured by brown patches. Sometimes the whole com- plexion changes to a darker hue. In one instance this was so marked, that both the family physician and the consultant diagnosticated a case of nerve- bronzing to be one of Addison’s disease. Another very remarkable, and often very mis- leading, symptom is an aneurismal pulsation of the aorta in the epigastrium. Repeatedly have patients been sent to me with the diagnosis of aortic aneurism, when their sole disease was nerve-exhaus- tion. Lastly, abnormalities in the sexual feeling are not wanting. In the majority, all desire is quenched, or intercourse is painful; in some the sexual feeling is increased ; in yet others, it is urgent, but it can- not be gratified ; in a few, the dreams are erotic. From this wealth, from this positive exuberance of symptoms, one would suppose that the diagnosis could not offer any difficulty whatever; but this is far from being the case. The laws governing woman’s complex organism cannot be codified; nor can we correctly label the lesions of cerebration proper or of innervation in general. Then the in- stinct of causality in man leads him to forget that things seen may come from things unseen, and to attribute preferably to the seeable and to the touch- able like phenomena, which may come from the unseeable and the untouchable. Naturally, then, we are likely to be misled : First, by symptoms ABUSE OF UTERINE TREATMENT. 15 which by common consent are deemed peculiar to uterine disease ; secondly, by the co-existence of actual uterine disease, to which we attach undue and overshadowing importance. Apart from these reasons there is yet another one : the human mind, bewildered by a multiplicity of details, does not catch the meaning of their aggregate. So Goethe’s traveller missed the forest by reason of the wilder- ness of trees around him, and the hero of our own national caricature “could not see the town, there were so many houses.” From a large experience I humbly offer to the reader the following watch-words as broad helps to diagnosis. In the first place, always bear in mind what another has pithily said, that “woman has some organs outside of the pelvis.” Secondly. Each neurotic case will usually have a tale of fret or grief, of cark and care, of wear and tear. Thirdly.' Scant or delayed or suppressed menstruation is far more frequently the result of nerve-exhaustion than of uterine disease. Fourthly. Anteflexion per se is not a pathological condition. It is so when associated with sterility or with painful menstruation, and only then does it need treatment. Fifthly. An irritable bladder is more often a nerve symptom than a uterine one. Sixthly. In a large number of cases of supposed or of actual uterine disease which display marked gastric disturbance, if the tongue be clean, the essential disease will be found to be neurotic ; and it must be treated so. Seventhly. Almost every supposed uterine case, characterized by excess of sensibility and by scantness of will- 16 ABUSE OF UTERINE TREATMENT. power, is essentially a neurosis. Eighthly. In the vast majority of cases in which the woman takes to her bed and stays there indefinitely, from some supposed uterine lesion, she is bed-ridden from her brain and not from her womb. I will go further, and assert that this will be the rule, even when the womb itself is displaced, or it is disordered by a disease or by a lesion that is not in itself exacting or dangerous to life. Ninthly. Groin aches and sore ovaries are far more commonly symptoms of nerve-exhaustion than of disease of the appendages. Finally. Uterine symptoms are not always present in cases of uterine disease. Nor when present, and even urgent, do they necessarily come from uterine disease, for they may be merely nerve-counterfeits of uterine disease. THE MEDICAL NEWS. A N ational WeeklyMedical Periodical, containing 28-32 Double- Columed Quarto Pages of Reading Matter in Each Issue. $5.00 per annum, post-paid. Uniting in itself the best characteristics of the magazine and the news- paper, The Medical News renders a service of exceptional value to the profession. It presents original articles, hospital notes and clinical lectures by the ablest writers and teachers of the day, discusses living topics editor ially in a clear and scholarly manner, and employs all the recent approved methods of medical journalism—the telegraph, reporters and a corps of special correspondents covering all the medical centres of the globe. It thus imparts, without loss of time, all advances of knowledge attained in the medical sciences. 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