HYGIENE VERSUS Surgery in Gynecology. BY JULIA W. CARPENTER, M.D., CINCINNATI, O. MEMBER OF THE ACADEMY OF MEDICINE OF CINCINNATI ; MEMBER OF THE OBSTETRICAL SOCIETY OF CINCINNATI ; MEMBER OF THE OHIO STATE MEDICAL SOCIETY *, MEMBER OF THE AMERICAN MEDICAL ASSOCIATION. [Reprinted from the American Journal op Obstetrics and Diseases of Women and Children, Yol. XXII., No. 5, 1889.] NEW YORK: WILLIAM WOOD & COMPANY, PUBLISHERS. 56 & 58 Lafayette Place. 1889. HYGIENE VERSUS Surgery in Gynecology. ' BY JULIA W. CARPENTER, M.D., CINCINNATI, O. V MEMBER OF THE ACADEMY OF MEDICINE OF CINCINNATI ; MEMBER OF THE OBSTETRICAL SOCIETY OF CINCINNATI ; MEMBER OF THE OHIO STATE MEDICAL SOCIETY ; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION. [Reprinted from the American Journal op Obstetrics and Diseases of Women and Children, Vol. XXII., No. 5, 1889.] NEW YOEK: WILLIAM WOOD & COMPANY, PUBLISHERS, 56 & 58 Lafayette Plage. 1889. HIM m* SIMM II MM*. In almost every department of medicine vigorous search is being made for the cause of disease with a view to its extermi- nation ; or, if that is not possible, with a view to a more certain method of treatment. Koch, already in possession of the palms of victory for having ferreted out the bacillus tuberculosis, takes his life in his hand and goes to dangerous fields to win new laurels by verifying to the medical world the cholera bacillus, or the cause of another disease. The search in every direction for germs and germicides is to prevent disease, not simply to repair damages. But there is one large depat tment of medicine where the causes of disease seem not to claim much attention, but wonder- ful talent and ingenuity are expended in devising ways and means of repair. This department is gynecology. One can read book after book, journal after journal, and the papers of all the brilliant specialists at the annual gatherings, and see almost no word of cause and prevention. One does not have to go to Africa or the isles of the sea to find the direct cause of some, and the predisposing cause of many of the dis- eases in this department. This cause is so near it is overlooked. It is also an insuperable obstacle to successful treatment, pro- longing cases, preventing permanent relief, and producing sur- ( gical cases that would otherwise never exist. 4 The-cause is the weight of clothing on the hips. It is sometimes easier to credit a new discovery than to be- lieve that an old custom is not right. But, nevertheless, instead of the many pounds resting on this part of the body, not one ounce can rest there with impunity. Reference is here made only to the ordinary dress, when not hygienically changed, and 1 Read before the Cincinnati Academy of Medicine, Feb. 4th, 1889. 4 Carpenter : Hygiene versus not at all to tight lacing. That has its place by the side of the Chinese foot and the Flat-head Indian, with this difference, that it exceeds both in its disastrous results. I have found three valuable papers, published within eight- een months, regarding the unhealthy dress of women; one by a neurologist, however, and two by those more interested in gynecology. How, while three papers have been published on prevention, there have been hundreds on surgery to repair damages. These three articles are chiefly on the injury done by the corset. "While that is of course vast, there are hundreds of women who wear instead a hygienic wraist, but the weight of clothing still resting on the hips puts them also, as well as the others, through a process more or less rapid towards invalidism. The reasons why there should be no weight on the hips, nor pressure on any part of the body from the seventh rib down, anatomy and physiology make very plain. The pliable walls of this part of the body are made up chiefly of muscles. How, the effect of pressure on muscle is well known. Pressure alone on muscle causes it to dwindle in size; and as its action is inter- fered wdtli at the same time, it becomes still smaller from dis- use. This result is seen in the muscles of a limb that has been bandaged a length of time on account of fracture. The large muscles that envelop this part of the body are always in just this state, for the pressure on them is greater than that of the ban- dages on the fractured limb. To get some idea of the loss to the body of this feeble state, one has only to recall what muscles these are and their func- tions. A good condition of the abdominal muscles is indis- pensable to perfect health. On the posterior surface are mus- cles intended to be large and powerful. First the latissimus dorsi, one of the largest in the body, and attached at its upper extremity to the humerus. The fleshy part of this muscle is subjected to the pressure of the closely-fitting waist, so arm power is lost. The chief muscle of importance in this connection, however, is the erector spince and its prolongations. The main part of this, a large, fleshy mass, fills in the space between the last rib and the crest of the ilium, just the place where the stricture of the clothing is greatest. This muscle is to maintain the spine in its normal position, and also serves to bend the body backwards. The normal position of the spine is erect, wdtli a graceful curve Surgery in Gynecology. 5 inward in the lower dorsal region. This muscle is so weak- ened that in a vast number of women the spine curves just the other way ; there is a most ungraceful curve outward. One is now so accustomed to this form that it is almost regarded as natural. This change of ctirve from concave to convex changes the relative position of organs within. Naturally the pelvis is at such an angle with the spinal column that the organs within it sustain very little weight from those above. In the altered position, all the viscera are in a direct line, and the lowest ones suffer from this increased weight. The weakening of this mus- cle alone will also explain many a backache. As to pressure on organs within, one might suppose that a part of the body left entirely free by nature it would not be safe to compress in any way. From the seventh rib to the ilium is the part thus left free. There is no bone but the vertebral column behind and the last five ribs, which are com- pressible, two being floating, and the other three easily movable by reason of their special cartilaginous attachment. One sees easily that there should be no pressure on the heart and lungs, but forgets why there should be none on the diges- tive organs. The two vital reasons, of course, are the following : These organs vary in size according to the amount of food and the stage of digestion. The second is their constant slow movement. This vermicular motion is checked by a vefy little pressure. Pressure here is the cause of many obscure forms of dyspepsia. For instance, a patient complained of emesis after meals. She was a strong, healthy girl, and no cause could be detected. Various aids to digestion were prescribed with no result. I then induced her to lessen considerably, but not entirely, the pressure over the digestive organs, and the trouble vanished. Now, if all bad effects were as evident and as disagreeable, a reform would be speedy. One sometimes says, Yes, that all applies to tight lacing, but the weight referred to rests on the hips. Well, what are the hips ? The only bony part is the crest of the ilium at the outer edge, and how wide is it ? The rest is simply soft parts, made up of the muscles referred to and internal organs beneath. And the shelf on which the weight hangs is greater or less ac- cording to the degree in which these parts are pushed inwards out of fheir natural curve. And the broader the hips, the 6 Carpenter : Hygiene versus wider the soft shelf and the greater the damage. Think of hanging weights on soft parts, and keeping muscles always on the stretch ! As the human body is not yet understood, as its recesses are so deep that chemistry and the microscope have not yet penetrated it not strange to interfere with the body regardless of consequences? The muscles that envelop the body are not the only mus- cular tissue that suffers. Lacerations of the cervix would not be the order of the day if muscle had its normal tonicity. This superincumbent weight not only injures the texture, but changes more or less the position of everything beneath it. Gynecologists agree that anteflexion rarely comes suddenly; that it is a progressive disease. Many others are likewise. I have been told by several authorities that at the beginning of our Civil War there were companies of zouaves that wore some part of the accoutrements attached to a belt around the waist. But so quickly was it disastrous, and so numerous were the men that were disabled with hernia, that they were obliged to discard the belt and suspend this same weight from straps over the shoulders, when there was no further trouble. .Now, it would have been just as sensible to go on devising all kinds of operations for hernia, instead of preventing it, as it is to work on in gynecology without removing this same weight. As long as there are weights above to press everything downwards, so long will there be a necessity for devising ope- rations to shorten ligaments, suture a displaced organ to the ab- dominal walls, and remove entire organs, otherwise healthy, for pain only. Instead of operating on organs pressed upon, re- move the pressure first; then if recourse to an operation is still necessary, there is some foundation for permanent success. If internal supports are used with this weight above, some- thing must suffer, for some of the tissues are then, so to speak, between the upper and the nether mill-stone. All this is no theory, but solid fact. Experience corroborates it. Removing this weight is a hidden secret of success, and the reason why I have succeeded a number of times where my predecessors failed. One marked instance is as follows: It is of interest, as the individual and the case were both well known. A young lady was doomed to the operation for the removal of both ovaries for extreme pain. This was the sentence of a surgeon who had performed this operation many times, with Surgery in Gynecology. 7 success it was thought. She had been under his care for a number of years, and, failing to give relief, he pronounced this verdict. She and her family were about resigned to endure these scenes every few weeks, until they could be reconciled to the operation. When, several years ago, she first put herself under my care, after a thorough investigation I told her if she would co-operate and re-arrange her clothing hygienically, she could probably be relieved. To this she gladly consented. The result of this, with treatment, was that in one month there was wonderful improvement, and in a few months she was ab- solutely well. The treatment was very simple, perhaps just what she had received before. The secret was, I simply re- moved the cause of the whole trouble in removing this super- incumbent weight, and the other treatment overcame the in- jurious effects; and thus one physician accomplished in a few months what another had failed to do in a number of years and would have removed a part of her body as a last resort. There was no change made in the external appearance, except that a very sunny face took the place of a sombre one. Another similar case is interesting on the other side. The young lady had had several physicians, without relief; had been sent abroad for her health, but returned just the same. Hygi- enic dressing found with her but little favor. She consented to a little change, and that, during the summer, with the lighter clothing of that season, brought an improvement most gratify- ing to her. But when winter came she preferred the fifteen- pound cloth dress with extreme pain to a lighter one without it, and she has her choice. Dressing as she does, there is no balm in Gilead for her except anodynes at the time or removal of part of her body. If there is a tight cord around the neck, one grows red in the face; and to remove the congestion, how useful are salves and lotions, fresh air and trips abroad ! Many operations are disap- pointing where success was expected. Voices like the follow- ing are now heard here and there. At a late meeting of the Phila. Co. Med. -Society when abdominal surgery was the sub- ject of discussion, Dr. Theopliilus Parvin said: “ I have seen a woman whose ovaries had been removed on account of pain; the suffering returned as severely as ever, and then the stump of each pedicle was taken away, but not the slightest benefit followed; a year after the last operation she was as bad as be- 8 Carpenter : Hygiene versus fore the first. I have myself removed the coccyx for well- marked coccygodinia, and for a time the benefit was marked; and then came just as severe pain in the sacrum as there pre- viously had been in the coccyx. Let us honestly and impar- tially-look at both sides of the picture; see the dark as well as the light offered, and not be carried away by contemplating only the latter.” Statements of this kind are bound to be heard more and more until the cause that predisposes to any pelvic trouble is removed. The number of operations performed is wonderful. One physician alone at Battle Creek, Mich., reports sixty-nine cases of shortening the round ligaments in two years. And though nearly all were regarded as successful, he says in his report: “ Alexander’s operation is not to be considered as a radical cure, but only as a most efficient aid to other means. It restores the organ to its normal position and gives it, so to speak, a new chance to stay there, if it can.” One may say, What can be done % Well, the facts remain just the same whether anything is done or not, but much can be done. It is not necessary to change the external appearance at all. Physicians must first see the necessity themselves. Then if they will teach this truth everywhere as they have oppor- tunity, and above all impress on each patient the fact that instead of the many pounds not one ounce should rest on this part of the body, pounds and pounds would be laid aside. Women would devise their own ways and mea/ns. It will not do simply to suspend the present weight from the shoulders. It is not in a small bulk as with the Zouave com- pany, so it can be lifted easily, but is so voluminous and cling- ing it presses in spite of suspension. So much weight must not he there to suspend. Teach every patient that all organs are pressed downward out of place, the circulation is interfered with and a venous stasis results, and that a continued congestion can be the starting point' for disease. Tell them that investigations point towards venous hyperemia as the condition for abnormal growths. A prospect of tumors would have some influence. ’Tis true, in teaching hygiene in this department an obstacle is met in the fact that most women do not see that their dress is an unhealthy one as long as they are not the victims of dis- Surgery in Gynecology. 9 ease. But health is not simply the absence of disease. They say, “ I am not conscious of any weight.” That is simply be- cause in all these muscles the muscular sense is lost. If these same persons dress hygienically for a few months, recover their muscular sense, and then go back to the old weights, they can hardly see how it was ever endured. If that part of the body was absolutely free, there would be a vast army of women in a normal condition, and not the weary, invalid corps that is adding to its ranks so fast that gynecolo- gists, multiplying as they are everywhere, will not be too numerous, and all the ingenuity spent in devising new opera- tions will not be able to stem the tide. Surgical cases, unavoidable, will always exist; but the great requisite in this department is hygiene—that is, acting in ac- cordance with the known laws of the body in order to pre- serve health and prevent disease.