WHAT I HAVH LEARNED TO UNLEARN IN GYNECOLOGY. BV WILLIAM GOODELL, M.D., PROFESSOR OP GYNECOLOGY IN THE UNIVERSITY OP PENNSYLVANIA. FROM THE MEDICAL NEWS, November 29, 1890. Reprinted from The Medical News, November 29, 1890. WHAT / HAVE LEARNED TO UNLEARN IN C YNECOLOGY. By WILLIAM GOODELL, M.D., PROFESSOR OF GYNECOLOGY IN THE UNIVERSITY OP PENNSYLVANIA. Every earnest worker in any field of the inexact sciences finds himself compelled to unlearn as well as to learn. The errors which he discovers and weeds out will usually be traditional teachings— the legacies of our forefathers—for we get many of our opinions, as well as many of our diseases, by heredity. What I have thus learned to unlearn in the treatment of woman’s diseases will be the burden of this paper. To begin, then, I have learned to unlearn the grandmotherly belief that the climacteric is in itself an entity, and that, as such, it is responsible for most of the ills of matronhood, and especially for that of menorrhagia. True, it must be conceded, that as an entity it does seem to disturb the vaso- motor system, and through it to cause many severe perturbations, such as tinglings and numbness, and sweating of the skin, flushes of heat and shivers of cold, emotional explosions, and a large group of hysterical symptoms. It can also lay claim to being an important factor in the causation of in- sanity. Yet, contrary to the prevalent lay and professional belief, how rarely can true uterine 2 GOODELL, haemorrhages or other uterine discharges be traced to the climacteric as a cause in itself. Yet many a poor woman has lost her health, her life, in- deed, by her own and her physician’s traditional belief, that her haemorrhages or other vaginal dis- charges are critical and due to the “ change-of- life,” as it is popularly called—a misnomer which too often leads to indolent diagnosis and slovenly therapeutics. What physician of any practice has not been called in to see some wretched sufferer, whose health has been crippled for months, or even for years, by haemorrhages or by other discharges from the sexual organs, which have been attributed to the “ change-of-life ” by her friends, or—what is more inexcusable—by the successive physicians whom she has consulted ? To the shame of the latter, they may not have made even a digital examination; yet a poly- pus or a fungoid degeneration of the endometrium, or a uterine fibroid, or a cancer of the cervix has been found by a more alert man, who does not believe in climacteric omnipotency. Never can I forget a case—not the only one—of a beautiful woman, be- loved by a large circle of friends and surrounded by every luxury that wealth could furnish, who was allowed by her physician to bleed almost literally to death. Why ? Because a polypus, being at first intra-uterine, was not recognized, and because her age justified, in his opinion, the diagnosis of “change-of-life.” This diagnosis having been made, no other vaginal examination was ever thought of by this physician. But when he was discharged and another one was called in, the latter found the ERRORS IN GYNECOLOGY. 3 polypus dangling in the vagina. She was bedridden and as translucent as alabaster when I twisted off the growth. The haemorrhages did not return, but neither did her health, and she died a few months later quite suddenly and very unexpectedly. In other cases, by the careless indolence of the physicians, begotten by this traditional belief in climacteric influences, I have been compelled to undeceive some poor woman and break as gently as possible to her, that the flow which she had joyfully accepted as a return of her monthly periods, and which she has mistaken for rejuvenescence, is the sure token of an incurable and far advanced cancer of the cervix. I have learned to unlearn the teaching that woman must not be subjected to a surgical opera- tion during her monthly flux. Our forefathers, from time immemorial, have thought and taught that the presence of a menstruating woman would pollute solemn religious rites, would sour milk, spoil the fermentation in wine-vats, and do much other mis- chief in a general way. Influenced by hoary tradi- tion, modern physicians very generally postpone all operative treatment until the flow has ceased. But why this delay, if time is precious and it enters as an important factor in the case? I have found menstruation to be the very best time to curette away fungous vegetations of the endometrium, for, being swollen, then, by the afflux of blood, they are larger than at any other time, and can the more readily be removed. There is, indeed, no surer way of checking a menorrhagia or of stopping a metrorrhagia than by curetting the womb during 4 GOODELL, the very flow. While I do not select this period for the removal of ovarian cysts, or for other abdominal work, such as the extirpation of the ovaries, of a kidney, of breaking up intestinal adhesions, etc., yet I have not hesitated to perform these operations at such a time, and I have never had reason to regret the course. The only operations that I should dis- like to perform during menstruation would be those involving the womb itself—such as the removal of a uterine fibroid, or a partial or a complete hysterec- tomy, and the various operations for uterine can- cer, etc. This exception is based upon the danger of haemorrhage arising from the increased vascular tension and pelvic hyperaemia, which exist during menstruation. This is well shown in fibroid tumor of the womb, in which this increased vascularity causes a corresponding increase in the size of the tumor itself. For obvious mechanical reasons it would also hardly be wise to sew up the torn cervix of a menstruating womb. I have learned to unlearn that anteflexion and anteversion in themselves—that is to say, as dis- placements merely, and without narrowing of the uterine canal—are necessarily pathological condi- tions of the womb. Text-books speak of them as such, and exhibit many ingenious forms of pessaries devised to rectify these so-called displacements. But very rarely indeed do I have to resort to them, and then only to a stem-pessary in anteflexions; for I find in almost every virgin or every barren woman that the womb in varying degrees is either bent for- ward or is tilted forward, and is apparently resting on the bladder. The mistake made, as I have ERRORS IN GYNECOLOGY. 5 more elaboratively shown in my Lessons in Gyne- cology rs in attributing to this natural position of the womb the various forms of pelvic trouble, especially that of irritability of the bladder, to which women are so liable. But the sympathy be- tween the brain and the bladder is a remarkably close one—so close, indeed, that some physiologists contend that “ every mental act in man is accom- panied by a contraction of the bladder.” The irri- tability of the bladder thus becomes one of the first symptoms of nervousness, to which everyone is liable. Many a lawyer before pleading an impor- tant case, and many a clergyman before delivering a discourse, is compelled from sheer nervousness to empty his bladder. So it is with the lower animals, which, when frightened, micturate involuntarily. A nervous bladder is then one of the earliest phe- nomena of a nervous brain—for nervousness means a deficient control of the higher nerve-centres over the lower ones—a lack of brain-control. Now, a hysterical girl, or a woman whose nervous system has given way under the strain of domestic cares, consults the physician for such ordinary symptoms of nerve-exhaustion as wakefulness, utter weariness, a bearing-down feeling, backache, and, perhaps, above all, an irritable bladder. Upon making a digital examination, he usually finds the fundus of the womb resting on the bladder, where it naturally should rest. At once he jumps to the conclusion that the whole trouble is due to pressure of the womb on the bladder—viz., to the existing natural ante- version or to the anteflexion, as the case may be. Enticed away by the vesical lapwing from the bot- 6 GOODELL, tom factor—the shattered nerves—he now makes local applications, and racks his brain to adapt or to devise some pessary capable of overcoming the sup- posed difficulty, heedless of the dilemma that the upward, or shoring, pressure of the pessary on the bladder must be greater than the counter, or down- ward, pressure of the womb, to which he attributes the vesical irritability. In the lying-in chamber the fear of septicaemia will ever haunt me, but I have long since abandoned the idea cherished by that class of waistless and wit- less nurses, now happily obsolescent, that the par- turient woman is to be swathed like a mummy and to be kept as immovable. What earthly harm can accrue to a woman after a natural labor if she turns over from side to side, sits up in bed, or even gets up to use the commode, if she feels like it, I cannot see. Natural labor is a physiological process, not a pathological one, but tradition has thrown around the lying-in bed a glamour of mischievous senti- ment. In relation to this let me express my disbelief that mammary abscess comes from “caked” breasts, or from breasts over-distended from a secretion of milk too great for the infant’s needs. Mammary abscess, in the suckling woman comes, in my opinion, from cracked nipples, and from cracked nipples alone. In proof of this let me ask my readers if any one of them has ever had a case of mastitis after a miscarriage, or one of gathered breast following a stillbirth—always pro- vided the breasts were let pretty much alone so far as pumping and sucking are concerned. Under ERRORS IN GYNECOLOGY. 7 these circumstances the unsucked and unpumped breast will swell up and grow painfully hard, but it will not inflame or suppurate. Let me not be understood as saying that an overdistended breast should not be relieved by sucking or by pumping; but the means employed for this relief must be so sparingly used, and at such long intervals, as not to crack the nipples. This immunity from mammary abscess after miscarriages and stillbirths is attributed by the physician to his local applications of bella- donna, or of other milk-drying drugs. But it comes from the absence of the exciting cause of cracked nipples—the sucking child. Long ago I came to the conclusion, that the womb, like the nose, has its own secretions; and that, because the cervical canal is stopped up with mucus, it is not to be treated any more harshly than a stopped-up nose. I was led to this belief from seeing very many cervical canals wholly closed up, even destroyed by the remedies applied to get rid of this mucus. Then again I found that, just as the nose secretes abundantly under the stimulus of the emotions, so the womb secretes more actively under a stimulus conveyed to impressionable nerves—so much so, indeed, that leucorrhcea is a common adjunct to nerve-prostration, and is then cured by the cure of its cause. This nasal analogy led me soon to think that even uterine catarrhs are not of such paramount importance as to merit heroic treatment, and that metritis and endometritis, in so far as symptoms are concerned, are often idle words. The mucus of a uterine catarrh is in quality very much the same as the mucus of a nasal catarrh, and 8 GOODELL, its secretion is in itself no more weakening. It is not a disease in itself, but is merely the symptom of a disease. It is not, therefore, that highly vitalized fluid, the loss of which, according to the traditional belief of the great majority of physicians, and of all women, saps the very citadel of life, brings on de- crepit and premature old age, and hastens its victim to an untimely grave. This widespread error is a relic of mediaeval ignorance, which believed in the existence of two seeds—the male and the female semen—and their admixture to insure conception. Hence leucorrhoea has erroneously come to mean pretty much the same thing as spermatorrhoea—a belief fostered by cunning quacks, who know how largely sex and sexuality make up our being and influence our credulity. As a corollary to this, let me add, that I have wholly freed myself from the belief that cellulitis is at the bottom of most female ailments, and that the hot-water douche is its cure-all. My experience teaches me that, save in some cases of active con- gestion or of acute inflammation of the pelvic organs, the hot douche is of questionable utility, and that its indiscriminate employment has done far more harm than good, especially when continued for any length of time. I cannot withhold the opinion that from its use both ovaritis, salpingitis, and peri-uterine inflammation have actually been set up by the overheating and the subsequent chilling of the pelvic organs. The crucial test of surgical research which cannot be gainsaid has shown that cellulitis is almost a myth, and that what have long been deemed exudation tumors and inflammatory ERRORS IN GYNECOLOGY. 9 deposits in the areolar tissue, are tubal and ovarian lesions. I have learned to unlearn the idea—and this was the hardest task of all—that uterine symptoms are always present in cases of uterine disease; or that, when present, they necessarily come from the uterine disease. The nerves are mighty mimes, the greatest of mimics, and they cheat us by their real- istic personations of organic disease, and especially of uterine disease. Hence it is that even seemingly urgent uterine symptoms may be merely nerve- counterfeits of uterine disease. I have, therefore, long since given up the belief, which with many amounts to a creed, that the womb is at the bottom of nearly every female ailment. Nerve-strain, or nerve-exhaustion, comes largely from the frets, the griefs, the worries, the carks and cares of life. Yet, although the imagination undoubt- edly affects it, it is not a mere whim or an imaginary disease, as all healthy women and most physicians think ; but it is the veriest of realities. When some flippant talker or some slipshod thinker scoffs at ner- vousness as a sham disorder, I say to him : “ Can the bribe of a principality keep you from blushing when you are ashamed, or from blanching when you are afraid? Under the flitting sense of shame or of fear these vasomotor disturbances are momentarily be- yond your control; and so they are in the nervous woman, whose vital organs are, as it were—not trans- iently, but—perpetually blushing and blanching under deficient brain-control over the lower nerve- centres.” Strangely enough, the most common symptoms of 10 GOODELL, nerve-disorder in women are the very ones which lay tradition and dogmatic empiricism attribute to womb disease. They are, in the order of their fre- quency, great weariness, and more or less of nervous- ness and of wakefulness; inability to walk any distance and a bearing-down feeling; headache, nape-ache, and backache; scant, or painful, or de- layed, or suppressed menstruation; cold feet, and an irritable bladder; general spinal and pelvic sore- ness, and pain in one ovary, usually the left, or in both ovaries. The sense of exhaustion is a remark- able 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, she has low spirits, and her arms and legs become numb so frequently that she fears palsy or paralysis. There are many other symptoms of nerve-strain, but since they are not so distinctively uterine, and, therefore, not so misleading, I shall not enumerate them. Now, let a nervous woman, with some of the foregoing group of symptoms recount them to a female friend, and she will be told that she has womb-disease. Let her consult a physician, and ten to one he will think the same thing and diligently hunt for some uterine lesion. If one be found, no matter how trifling, he will attach to it undue im- portance, and treat it heroically as the peccant organ. If no visible disease of the sexual organs be discoverable, he will lay the blame on the invisible endometrium or on the unseeable ovaries, and con- tinue the local treatment In any event, whatever ERRORS IN GYNECOLOGY. 11 the inlook or the outlook, a local treatment is bound to be the issue. Until my eyes were opened to the harlequin tricks of the nerves, I have repeatedly made the same mistake, and I now see it made over and over again by other physicians. To give but two recent instances out of very many : Not long ago a lady was sent to me by a very in- telligent physician to have a cervical tear repaired. She had been seen by several physicians, all of whom had treated her locally, and all had con- curred in the opinion expressed by my friend. Her most pronounced symptoms were insomnia, unend- ing weariness, excessive nervousness, great dread of being alone, severe bearing-down, painful locomo- tion, constant backache, and an extremely irritable bladder which gave her no peace day or night. She had in addition most of the canonical uterine symptoms. Being sure that a comparatively trifling tear of the cervix could not give rise to so many exacting symptoms, although she herself attributed them to this cause, I closely cross-questioned her, and soon discovered the source of the mischief. After a rather difficult labor—her sole one—she had given birth to a still child. This was a great disap- pointment, yet she was convalescing naturally, when a great conflagration broke out in her city. After destroying most of this city it swept onward toward her house. Her valuables were hastily packed up, and she was bundled up ready to be carried away at a moment’s notice. Fortunately the fire was put out at the second house from hers. Since then she had never been well. It was not the cervical tear that had wrecked her health, but disappointed motherhood, and the noise, 12 GOODELL, the tumult, the fear, the long-drawn-out agony of suspense. The second case gave the following history : She was aged forty-two years, and was the mother of one child, now twelve years old. She had sharp pain in the right ovary, burning aches in the left one, and difficult locomotion. A sensating of ting- ling, prickling, and stinging heat pervaded her whole left side. Her left eye had wavering vision, as if she were looking through heated air. The cata- menia, formerly scant and painful, were replaced by an abundant leucorrhoea. Her bladder was irritable and needed emptying day and night. She was tired all the time, lay awake most of the night, and her sleep was troubled by distressing dreams. A well- known oculist had cut the muscles of her eyes, several physicians had treated her locally off and on for many years, and she was now sent to me to decide the question of the removal of her ovaries. The womb lay in the first stage of retroversion, there was some endometritis, and the left ovary was ten- der and reachable. Finding, as in the foregoing case, that her symptoms were out of all proportion to the local lesions, I suspected nerve-trouble, which her history confirmed. Ten years ago, while sailing with her husband across a lake, a storm overtook them. The boat filled with water and, after a des- perate struggle, they barely reached the shore. Two years later her nerves, still much shaken by this narrow escape from drowning, received another shock. A burglar broke into her home, and her husband had, in her hearing, a fierce and noisy hand-to-hand fight with him. One more year passed, and she met with a railroad accident, in which twelve persons were killed, but she wras un- injured. This final shock completely shattered her ERRORS IN GYNECOLOGY. 13 nervous system, and she was plainly suffering from a sore brain, and not from sore ovaries. In one word, it was the old, old story of wounded nerves counterfeiting a wounded womb. I have learned yet another trick of the nerves: that when riotous from being under-fed, from over- work, or from lack of discipline, they billet them- selves, like an insolent soldiery, on some maimed organ and hold high revel there. For instance, a woman, hitherto in perfect health, may have an ad- herent or a dislocated ovary, or a torn cervix, or a narrow cervical canal, or a slight displacement of the womb—lesions which may have given her no appreciable trouble whatever. But let her nervous system become unstrung, and at once, through dis- turbances in the circulation both of the nerve-fluid and of the blood-fluid, there set in vesical, uterine, or ovarian symptoms, which may indeed reach so exacting a pitch as to demand a local treatment. Nor are the sexual organs the only ones thus affected. Every weakened organ in the body is liable to such functional outbreaks. The stomach rejects its food, the bowels either refuse to act or else they are very loose, the heart loses its rhythm and beats irregu- larly, the vocal cords relax and the voice cannot be raised above a whisper, and almost every sphincter muscle in the body behaves as if it were insane. I have known a woman in her nervous attacks to be- come as jaundiced as if she had the liver of a Stras- burg goose. The yellow color was fugitive, but it lasted longer than the emotion that caused it. Even the eyes, which before may have exhibited to their owner no visual defect, now blink painfully at the 14 GOODELL, light or may cause violent headaches, which glasses alone can allay. In the following case various organs were thus affected: An unmarried lady in splendid health and with a magnificent physique, had unusual muscular strength, which she was fond of testing. One day, while wrestling with her brother, which she often did, she felt something give way in the pelvis, and shortly after this her health began to fail. Her monthly periods, hitherto painless, now gave her acute suf- fering, and a persistent leucorrhoea soiled her linen. The left ovary throbbed with a constant ache, walk- ing became painful, the bladder grew irritable, and the stomach began to reject its food. From slug- gish circulation, local congestions took place, par- ticularly in the head and in the pelvis. Thus, when she stood up, the pelvic organs seemed to fill up with blood and painful pelvic throbs beat time with her pulse. From these she got relief by sitting with her knees raised up, or by lying with her feet higher than her head. Soon insomnia, photophobia, and dreadful headaches set in. These were lollowed by illusions when her eyes were closed, which vanished when she opened them. She heard imaginary con- versations and saw unpleasant sights. She became morose and irascible, and kept much by herself; in one word, her mind hovered on that ill-defined bor- derland between sanity and insanity. The wrestling episode and her many orthodox uterine symptoms misled every one, including her- self, her family, and several physicians, who attri- buted everything to uterine disease and treated her accordingly. She had much local treatment of the usual kind, and more for supposed anteflexion. Getting no better, she travelled many miles to con- sult me. My examination of her revealed merely ERRORS IN GYNECOLOGY. 15 glairy mucus in the cervical canal, some tenderness over the left ovary, which was slightly displaced, and the natural anteflexion of a virginal womb. These lesions were too trivial to account for her lamentable condition, and I looked to her history for an explanation. This clearly satisfied me that she was suffering from nerve-breakdown. This diagnosis was a great surprise to her and to her mother, who accompanied her; but, notwithstand- ing her contrary convictions, she entered my private hospital. With the exception of a few douches of corrosive sublimate for the leucorrhcea, her uterine organs were let severely alone, and she was treated merely for her nerves. Her friends were greatly dissatisfied with this treatment, and at their instance a near medical relative wrote me a letter in which, after criticising my treatment, he urged upon my attention the wrestling match and the uterine char- acter of the symptoms. At the end of six weeks she left me very greatly improved in every respect, but as her headaches still troubled her more or less, I asked Dr. de Schvveinitz to examine her eyes. He found some astigmatism in one eye, and “ the high- est degree of hypermetropia which he had ever seen, excepting in two other cases.” Suitable glasses remedied these defects, and she afterward progressively improved—so much so, that eight months later I received from her a most grateful letter of thanks. Further, the physician himself who had criticised my treatment of her, wTote me quite recently, that he was about to send me a patient with analogous symptoms, who had been unrelieved by a long course of uterine treatment. Just as headache does not necessarily mean brain disease, so ovary-ache does not necessarily mean ovarian disease. Yet time and again—and I say this 16 ERRORS IN GYNECOLOGY. deliberately—have ladies been sent to my private hospital to have their ovaries taken out, when the whole mischief had started from some mental worry. Their ovaries were sound, but their nerves were not, and no operation was needed for their cure. So misleading, indeed, are the symptoms of a jaded brain or of other nerve-strain, under the uterine livery in which they are often clad, that I have recently known a jilted maiden to be treated by a cup-and- stem pessary, and a bereaved mother to be douched and tamponned and cauterized for a twelvemonth. Such cases, even when accompanied by actual uterine disease, are not bettered by merely local treatment. Nor are medicines by themselves of much avail. What they need is massage, perhaps electricity, and that freedom from care which strict seclusion gives. Hope should be infused into every case, and, above all, there must be imported into it the personality of the physician. It was not the staff of the prophet that awakened the dead child ; but death was quickened into life when the prophet threw himself upon its body and breathed into it of his own intense vitality. As the outcome of much that I have learned to unlearn, I have arrived at this very short gyneco- logical creed : I believe that the physician who recognizes the complexity of woman’s nervous or- ganization and appreciates its tyranny, will touch her well-being at more points and with a keener perception of its wants, than the one who holds the opinion that woman is woman because she has a womb. THE MEDICAL NEWS. A National Weekly Medical Periodical, containing 24-28 Double- Columned Quarto Pages of Reading Matter in Each Issue. $4.00 per annum, post-paid. The year 1890 witnesses important changes in The Medical News resulting from a careful study of the needs of the profession. Its price has been reduced, and its bulk also, though in less proportion. 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