Etiology of Pelvic Diseases in Women and Their Prophylaxis. BY X. 0. WERDER, M. D., PITTSBURGH, PA. Read before the Allegheny County Medical Society, November 21, 1893. Reprinted f rom the Pittsburgh Medical Review of November; 1893) Etiology of Pelvic Diseases in Women and Their Prophylaxis. BY X. O. WERDER, M. D., PITTSBURGH, PA. Read before the Allegheny County Medical Society, November 21, 1893. PITTSBURGH: Murdoch, Kerr & Co., Printers. 53 Ninth Street. Etiology of Pelvic Diseases in Women and Their Prophylaxis. X. O. WERDER, M. D. The question often asked the physician, how is it that such a large percentage of the present generation of women is affected with pelvic diseases, has given me, and no doubt, many of you, much food for reflection. Is the number of sufferers from diseases of the pelvic organs increasing, and if so, is this increase real or is it only apparent? No doubt many cases of uterine diseases in for- mer years, when less was known of pelvic pathology, were not recognized and treated for other disorders ; the kidney, spine and liver were blamed frequently when they were entirely innocent of any mischief; periton- itis, typhoid and malarial fevers were diag- nosticated in cases which we now unhesitat- ingly pronounce inflammatory or septic con- ditions due to the presence of pus in the pelvis ; " change of life " was a favorite di- agnosis for all pelvic ills between the age of thirty-five and fifty, and perfectly satisfac- tory to both patient and physician. But granting that many cases went to the grave or through a miserable life with a wrong di- agnosis, it seems to me unquestionable that pelvic diseases are more frequent now than formerly and that in spite of the great ad- vances made in the treatment of the puer- pera, which period we naturally look upon as the foundation of much of the misery and suffering of womanhood. It must be a mat- ter of deep interest to all practitioners who treat these unfortunate women, to study the causes of this increase of pelvic trouble, and in doing so to find the remedies which will check this growing evil among our American women. Fortunately, the pathol- ogy of pelvic disease is at present so well defined, that its etiology is no longer a mat- ter of conjecture or theory, but consists of facts well proven and easily demonstrable, and I will say unhesitatingly, very often preventable. Indeed, few other diseases are under such easy control of the family phy- sician as those of the pelvic organs, if he uses the prophylactic resources at his com- mand carefully and conscientiously. For this reason you will pardon me, if I bring before you this important subject, a discussion of which by this learned body can only be pro- ductive of the greatest amount of good. The principal causes of the diseases of women are: 1. Imperfect development of the sexual organs. 2. Septic inflammations and traumatisms follow- ing child-birth and abortions. 3. Gonorrhoea. 4. Sins against hygiene and nature. 1. Imperfect development of the sexual organs. In this class I will very briefly consider those causes which interfere with the physiological evolution of the pelvic or- gans at the time of puberty, the parts most commonly affected being the cervix and the tubes, resulting in anteflexion and occasion- ally retroflexion, and in convoluted or infan- tile tubes. These conditions are accompa- nied by the tardy appearance of the men- strual function, painful and irregular men- struation, with their array of reflex and neurotic symptoms, and leading frequently to sterility. That imperfect development of the reproductive organs must be a very com- mon condition is shown by the large number of young girls scarcely entered on the period of puberty, who are suffering from dysmenor- rhoea, leucorrhoea, and other symptoms re- ferable to the pelvic organs. The causes 4 leading to this are many, of which I will, however, only give a few. Among the bet- ter classes, who suffer perhaps more from this trouble than the poorer ones, not infre- quently our modern methods of education are at fault, which compel the girl ap- proaching puberty to expend all her vital forces in mastering a multiplicity of stud- ies. Instead of trying to develop her phys- ical energies by healthful out-door exercise, fresh air. good and nourishing food, cheerful companionship, most of her time is consumed in crowded, often ill-ventilated school- rooms, her nervous forces are taxed to their utmost capacity preparing for examinations, her ambitions are stimulated both by teach- ers and parents, with the result that her ner- vous system is developed at the expense of the rest of her- body, all her vital forces are expended on intellectual work when they are needed to develop her sexual organs. The poor girl in the factory, shop or store is at the same disadvantage ; she also suf- fers from lack of fresh air, out-door exercise, and abundance of good, nourishing food, her surplus of strength intended by nature to be expended in the evolution of her re- productive organs, is consumed by hard work, and the result is a crippled sexual ap- paratus. A timely warning by the family physician who frequently sees these cases when a change in the habits and hygienic sur- roundings of the patient, will often be able to nip the evil in the bud, can prevent un- told misery in later life. 2. Septic inflammation and traumatisms following puerperium and abortions. It is now a generally recognized fact that febrile conditions during the puerperium are gener- ally due to infection by pathogenic micro- organisms introduced into the genital canal from without, not differing materially from ordinary wound infection in other parts of the body. The puerperal uterus, with its large raw surface left after the expulsion of the placenta, and its great abundance of blood and lymph channels ready to receive these dangerous micro-organisms, is indeed, extremely liable to infection. Puerperal in- fection is primarily always exogenous in origin, and auto-infeetion, in the strict sense of the the word, in my opinion, does not ex- ist ; that is to say, the poison in all cases is introduced from without. It is not always necessary that the hand of the accoucheur or his instruments should be the carriers of the septic matter, for we know from actual observation that the vagina and not infre- quently even the cervix, sometimes contain pathogenic micro-organisms in an apparent- ly healthy puerpera which the fingers of the obstetrician, during his examination, may deposit in the uterine cavity, where they, placed in a more congenial soil, may develop their nefarious activity. This must be very exceptional, however, because in the cases in which the pathogenic germs are present in the vagina they very soon become neutral- ized, so to speak; for we know from the ob- servations of Doederlein that the vaginal secretion contains a bacillus which produces an acid allied to lactic acid having bacterio- cidal properties ; at least, vaginal secretion containing streptococci pyogenes, staphylo- cocci and other septic germs seems non- poisonous, as it can be injected into animals with impunity. This explains the remark- able experience of Leopold who, without antiseptic vaginal douches, had in 919 cases delivered by him without internal examina- tions, only 12 cases, or 1.3 per cent., in which there was any elevation of tempera- ture, in none, however, of a serious degree. The conclusion therefore, is evident, that in a given case of puerperal sepsis the pois- on has been introduced into the birth-canal during labor. The late lamented Schroeder was so firmly impressed with this fact that while I was attending his clinic, he brought in a patient dying from puerperal sepsis and called her attendant, one of the senior stu- dents, down to her bed-side, in the public clinic and before a very large class, and asked him to feel her cold, clammy hands and look at her stertorous breathing, and after telling him in kind, but very earnest words that this was his work, he turned to the class and appealed in the most touch- ing manner to their conscience, point- 5 ing to the poor dying woman as an example of the result of carelessness in our antisep- tic precautions. This pathetic and dramatic scene made an indellible impression on me and no doubt on all others witnessing it. But it is not the cases of septic puerperal peritonitis rapidly leading to fatal termina- tions, which concern us here ; it is the mild- er forms of septic infection, such as septic endometritis, salpingitis and oophoritis, which often persist after the puerperal pe- riod, to which I will call your attention. While under careful treatment these condi- tions, no doubt, frequently -get well, their tendency is to become chronic and to give rise to frequent acute exacerbations of pel- vic peritonitis with the formation of adhe- sions to the neighboring structures, often- times resulting in more or less serious tubal and ovarian lesions, accompanied not only by chronic invalidism, but frequently grave danger to life. These conditions can in most cases be avoided by the careful ob- stetrician who has acquired the necessary details of strict asepsis and antisepsis. The traumatisms caused in the delivery of the child, the most frequent of which are lacerations of the cervix and the vaginal outlet, not only give rise to great misery and suffering in the subsequent history of the patient, but they are a well known source of danger through infection during the lying-in period. The relation of the lac- erated cervix to subinvolution of the uter- us and endometritis, so well described by Emmet, are generally recognized. More important even in their after effects are in- juries to the pelvic floor. With the injury to the levator ani muscle and the pelvic fascia, the pelvic support is weakened and a foundation is laid for every form of prolapse of the pelvic viscera; rectocele, cystocele and prolapsus uteri, have nearly always been preceded by laceration of these important structures. While these traumatisms are not always avoidable, a few sutures inserted not merely through the skin of the external perineum, but beginning in the vagina at the apex of the vaginal tear, will generally restore the anatomical relation of the parts and save the patient years of misery and suffering. What has been said in regard to puerperal infection is equally applicable to abortion. Small portions of the decidua engrafted upon the uterine mucosa frequently become centres of infection. This is particularly true of criminal abortions where dirty in- struments are so frequently the carriers of the infecting organisms. In addition to the infection we have frequently as a source of disease the carelessness and neglect of the patient, who, either from indifference or to avoid suspicion, does not give herself the rest and care which her condition requires ; therefore, subinvolution and displacements are not uncommon sequelfe. A reputable and intelligent member of this society has made the calculation that 5,000 infants are an- nually sacrificed in Allegheny county for the purpose of escaping the duties of maternity or of concealing the shame consequent to it; how many of these suffer as a just penal- ty for their murderous crime, pelvic diseases and chronic invalidism I 3. Gonorrhoea. Gonorrhoea and puerpe- ral sepsis are the cause of 95 per cent, of the tubo-ovarian diseases of women ; which of the two furnish the largest contingent of these diseases is a question in which author- ities differ. Until a very few years ago gonorrhoea in the female was considered a mild disease compared to that in the male and of little consequence excepting the harm it produces in the poor man. This was the teaching I received in the very city in which a few years previous, Noeggerath had made his famous observations on the disastrous results of the gonorrhoeal poison in females, published in his little book which has since become classical. More recent experience has changed the old teaching com- pletely and has confirmed the observations of Noeggerath, though in some points we are not quite willing to adopt his extreme views. Gonorrhoea is now generally recognized to be due to a micro-organism, the gonococ- cus which, if present, is pathognomonic of the disease ; its absence, however, does by 6 no means prove its non-existence, as it fre- quently cannot be demonstrated in the more chronic forms. The reason of this is the small number often present in the secretion of chronic cases, and the fact, proved by Werthheimer, that only the young individu- als can be stained by the watery aniline col- ors, older ones remaining pale and poorly out- lined, or they may even, when poorly nour- ished, change their characteristic form, be- coming unrecognizable under the micro- scope ; but when transferred to new soil, they resume their characteristic form and regain new vigor and virulence. This shows that the microscope is not always sufficient to prove the presence or absence of gonor- rhoea, but that it is often necessary to resort to cultures. Noeggerath and Tait claim that gonorrhoea in the male is an incurable disease ; that while all symptoms and signs may for a time completely disappear, the power of infection still remains; they call this form latent gon- orrhoea. Breese, of Berlin, who has given this matter much attention, bad every hus- band whose wife he found suffering from gonorrhoea, carefully examined by a genito- urinary specialist,and found in nearly all cases distinct anatomical changes in the male ure- thra, circumscribed and diffuse urethritis, beginning strictures, etc., but very rarely gonococci. He therefore, forms the conclu- sion that there is no latent gonorrhoea, but that the husband at the time of infecting his wife, has inflammatory changes in his urethra of greater or less extent, but sufficient to be able to be detected by a careful en- doscopy and urinalysis ; in other words, he suffers from chronic gonorrhoea. This chron- ic course may extend over years, even to old age, for strictures, as we know, usually oc- cur years after infection. As long as there are such inflammatory processes present in the urethra, there are, no doubt, some gono- cocci hidden somewhere in the neighboring tissues and glands, though perhaps attenu- ated, exhausted and starving, but under the influence of some inflammatory reaction or the excessive venery of the newly married man an increased amount of blood is car- ried to the dying gonococcus, he becomes in- vigorated and youthful and when trans- planted into the healthy genitalia of the wife, he is able to develop his usual disas- trous activity, and the innocent, loving and blooming girl in a few months is often trans- formed into a poor and helpless invalid. This is not a picture of fancy, but an every-day experience of the observant physi- cian. Let me illustrate this by a case from my case-book. A young man contracted gonorrhoea for the first time in March, 1890, and placed himself under the care of a very capable practitioner until he was discharged cured. In October, several months after- wards, he went back to his attending phy- sician and consulted him as to the advisa- bility of marriage; he was told that he was perfectly well and need have no fears of en- tering the married state. He, therefore, was married a month later, in November, to a perfectly healthy, hearty young lady who never knew what sickness was. In the same month his discharge returned, when he con- sulted a reputable specialist who told him not to be alarmed as there was no danger to his wife. In December, about a month or six weeks after marriage, his wife be- gan to complain of some vague pains in the pelvis, and shortly afterwards was seized with severe pains in her left shoulder which became very tender, swollen and stiff, not allowing the slightest motion of the arm. The attending physicien called it articular rheumatism, but his treatment did not al- leviate her suffering. For fully five months she suffered with this rheumatism which, however, never left her shoulder and never affected any othei' joint. Other physicians were tried, but with very little relief. In May, 1891, I was called in more for the pur- pose of treating her for some pelvic trouble which during this time had caused her much suffering. The most intense pain was in the region of her right ovary; her menses, which before marriage were never painful, were accompanied by severe cramps. An examination revealed an extremely tender and somewhat enlarged right ovary. With her history to guide me and her tubo-ova- 7 rian inflammation, I at once suspected gonor- rhoea as the existing cause of both her pel- vic trouble and her rheumatism. On ques- tioning her husband I obtained the above history which confirmed my diagnosis. Her rheumatism and pelvic trouble slowly im- proved, so that she was able to take a trip to Europe during the lattei- part of the sum- mer, from which she returned much im- proved in health. Within the last few weeks I have been able to make an examina- tion, and found her in pretty fair health, but with some pains referable to her pelvis ; both ovaries and tubes are slightly enlarged and adherent ; she has dysmenorrhoea, occa- sionally some slight menorrhagia and met- rorrhagia. It is needless to say that she has remained sterile, though married now three years. I have related the history of this case somewhat in detail, because it is very in- structive. This is by no means an excep- tional case. I know of dozens, perhaps less striking and typical, but subject to the same cause and effect, many of them with much more pronounced local trouble. The gonococcus, fortunately does not al- ways produce these serious results in the female. He may become arrested in the cervix, his most favorite and obstinate habi- tat, and may perish there, but when he reaches the tubes and ovaries, the normal exercise of their functions becomes almost invariably seriously damaged and complete restoration to healthy action is scarcely to be expected. It is true, a quiescent stage may follow the more or less active inflam- matory condition, which in the absence of any disturbing influences may last for months and years, but if we have hoped to have obtained a cure, an explosion sooner or later in the form of an acute pelvic periton- itis will often awaken us from our illusory dream. The physician, therefore, who treats gon- orrhoea assumes a very grave responsibility. Not only is it his duty to make clear to his client the serious nature of his disease and the importance of prompt and careful treat- ment, but he cannot exercise too much care in his decision when asked in regard to the advisability of marriage. In such cases where any doubt exists as to whether the patient is completely cured, and in the pres- ent state of our knowledge this would seem to include the majority-not only the micro- scope, but also the endoscope, should be brought to our aid. 4. Sins against hygiene and nature. Though there are many diseases of the pel- vic organs which are directly attributable to bad hygiene and faulty habits of living, time will not permit me to consider them, as I have already exhausted your patience ; I will simply refer to constipation so common in women, producing not only pelvic conges- tion and predisposing to uterine displace- ments, but also constitutional derangements from toxic absorption ; and to the injury done by corsets, tight lacing and the drag- ging of skirts fastened around the waist. There is one point, however, which I can- not pass by without, at least, a few remarks, because insufficient attention is given to it in our literature, and yet it is a growing evil, one whose pernicious tendencies are not confined to individuals, but are bound to extend to our whole nation ; I refer to sins against nature, to masturbation and more particularly, to conjugal onanism. That this evil has assumed enormous dimensions in this country, is well illustrated in our last census, according to which our birth-rate has diminished quite considerably. It is not my intention to pose as a reformer or a moralist, but my own experiences and ob- servations convince me that at the present time when maternity is regarded by many as a evil rather than a blessing, conjugal onanism is to be- considered as one of the important factors when looking into the causes leading to an increase of uterine dis- ease. Goodell, who in his " Lessons in Gy- necology," has contributed an excellent ar- ticle on this subject which, by the way, has often served me better than any arguments I could use myself when dealing with hus- bands and wives pestering me for advice to limit their families, he says: " That coition is innocuous only when complete in 8 both husband and wife and when the germinal fluid bathes her reproductive organs and again, "I believe that the semen itself, aided of course, by the general relaxation follow- ing the crisis, has a special property of al- laying the congestive orgasm and the vascu- lar turgescence of the venereal excitement. Be the mode what it may, at any rate, so much disorganization of uterine structure takes place in those women who have kept themselves sterile, that they are rarely free from some womb disorder, and when, as they advance in life, they yearn to have children, they find to their dismay that they cannot conceive." How often have I been called upon to treat sterility brought about, without a doubt, by such contemptible practices! It is not a mere coincidence that I have three such patients under my care now, who implored me with tears in their eyes to do everything in my power to cure them of their sterility. They all had had children, one had two, the other two had one, but they are all dead. Since they are childless they clamor for that which, accord- ing to their own voluntary confession, they used every means known to them to pre- vent. One of these I had an opportunity to examine over two years ago for suspected pregnancy, when I found her pelvic or- gans perfectly normal; now she has endo- metritis and salpingitis, with adherent ad- nexa, which means hopeless sterility; an- other I attended in her two labors a number of years ago, and for several years subse- quently, and know that she was perfectly well; now she suffers from about the same condition as the one mentioned. Of these two cases I feel absolutely confident that it was conjugal onanism and that alone which is to blame for their present condition. Nature, indeed, punishes very severely the violation of her sacred laws, and many who are now trangressing them, would hesitate were they cognizant of the severe penalty, of these shameful abuses, which await them. The physician who is so often made the confidant of these practices, would prove a benefactor, not only of the families in his care, but of a whole nation, by a few kind words of ad- vice, offered at the proper time in an ear- nest and discreet manner. There are many other points, more or less important etiological factors in the diseases of women, the consideration of which would very properly belong within the scope of this paper. I may allude to the influence of some general diseases, such as anemia, tu- berculosis, syphilis, and then again, diseases in distant organs with secondary involve- ment of the pelvic viscera, viz., cardiac, renal and hepatic disorders, but time will not permit to discuss them here. I have tried to bring such causes prominently before you which, in my opinion, play the most impor- tant role in the etiology of pelvic diseases, but the omissions, which I humbly acknowl- edge are many, will no doubt find full recog- nition in the discussion. In conclusion, I believe that there is undoubtedly an increase of pelvic dis- eases in our present generation of women. The causes chiefly responsible for this in- crease are, in my humble judgment: 1. Our modern education of young girls, over-burdening them with studies and neg- lecting their physical development and well- being ; and overwork of the growing girl in factories, stores and shops. 2. A general disregard of the laws of hygiene in our mode of living and dressing. 3. Criminal abortion, which at the pres- ent time has assumed alarming proportions. 4 Gonorrhoea, which with the wonderful development of our country and particular- ly our large cities, and our modern facilities for communication, finds increased opportu- nities for propagation. And lastly, but not least, the wide-spread practice of family limitations by that form of masturbation, conjugal onanism. The family physician whose duty is not only to relieve suffering, but to prevent it, where possible, in the families entrusted to his care, has it very often in his power to avert this growing affliction of our women. Let him exercise these noble duties of his calling conscientiously and consider how much easier it often is to prevent these dis- eases than to cure them.