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urday and informed us that the cotton had come out. The womb was again reduced, supported in position by a ring, and she was ordered alum injections.
Now, such cases can be cured without resorting to operative procedures, and this cure can be accomplished by supporting the womb and using astringent injections. Of course the laceration and eversion can only be cured by operation, and later, when the woman is in better condition we will so operate. But now she will have cotton tampons, saturated with glycerine and tannin. These measures, persistently used, will make a new creature of her. Some women will manage to get along very comfortably in this way, using also a T shaped bandage to hold the tampons, even where the womb may have ordinarily hung down even to the knees.
MISCARRIAGES FROM RETROFLEXION. I had a woman come to me yesterday and she has kindly consented to come again to-day, who is twenty-six years old, has been married four years and has had five miscarriages, not being able to carry a single product of conception to maturity. Now this case is the more peculiar, in that the woman seeks relief for the condition that causes the miscarriages. In your professional life you will be frequently be consulted by women who do not want to have children, as to the best means to prevent conception, but you will rarely have them seek your aid to enable them to bear children: Your only answer to those who desire to prevent conception is that of absence from intercourse. There is, I say emphatically, no other safe measure, no other means that is not fraught with danger. The only way is to sacrifice on the altar of duty all
. human lust. Nature's laws can not be violated with impunity. Remember the story of the bird that stole some food from the altar of the gods, he also took with it a burning coal that destroyed his nest and his young; so also if you violate the laws of nature, you will carry from the altar of duty a flaming coal, that will burn to your sorrow and injury. To
go back to our patient, she is now about six weeks pregnant and she comes to see whether we can not do something to enable her to go to full term, for both she and her husband long for children. Well, you will hear some most excellent authorities teach that in these cases of habitual abortion there is nearly always a specific cause, and you are advised to institute anti-syphilitic treatment. I can not, however, endorse this teaching, I do not think that this is such a universal cause, and I do not think that you would be justified in giving remedies that are intended to combat a particular factor in the system, simply on this vague and maybe unfounded suspicion. I always explain this matter of suspician by relating the story of the Dutchman who thrashed his son Hans.
As the son sat sulking by the fire, the old man abruptly addressed him, saying, “Hans, vat you tink?" “I tink nodụngs, dad," was the reply. “ You lie, Hans, you tink damn, I lick you again.” So this Dutchman thought his son thought damn, because he thought he did, so is it with this suspicion of syphilis in these cases, we have no really good grounds for holding such suspicion. It is a cause, of course, but I think that it will usually make its presence manifest to us in other ways as well. We should then, I think, only resort to such remedies when we have utterly failed to account for the miscarriages in any other way. If it were due to syphilis, we ought to be able to get some kind of a history to guide us in that direction, it is hardly likely that the disease would be so wonderfully concealed. So that it seems to me a blind way of giving medicine. If we belonged to that school whose remedies are powerless to do harm, even if they do no good; if we were homeopaths then it would not make so much difference, but we ought not to employ these powerful remedies unless there are clear indications for their use. Now, as I have said, this woman is six weeks pregnant, and how can we accede to her request and prevent another miscarriage? Without looking far, I have discovered a cause for these accidents, for I have found a retroverted uterus. I reason that this is the cause as follows: The miscarriages, she tells us, usually occur between the second and third month, and it is at this time that the enlarging uterus, seeking to escape from the cavity of the pelvis that it may find more room for its phenominal development, will, if retroverted, impinge against the sacrum, and thus have its development interfered with. There is no blame to be attached to the husband in this case, for, with as much instinct as the lower animals, and with much more sense than the majority of the superior animals, he has absolutely refrained from intercourse since he ascertained that his wife was pregnant. Now, she is six weeks pregnant, and, arguing from the previous accidents, she will have a miscarriage during the coming month, if something is not done to prevent it. Well, then, what shall we do? The first tning is to replace the womb. Displacements, particularly posterior ones, are, as I have said, very frequent causes of miscarriages. But how shall we replace the organ? It has been very generally the custom to replace a displaced uterus by the aid of the sound passed into its cavity. But, of course, for obvious reasons, we could not resort to that procedure here, for by so doing, we would surely bring about that which we are endeavoring to prevent. We may safely pass our finger into the posterior cul-de-sac, and by gentle pressure endeavor to force forward the fundus that is bent backwack, or if we can not thus get up high enough, the finger may be introduced into the rectum, at the same time aiding this manipulation by supra-pubic pressure from in front; or, if this does not suffice, we may introduce a tenaculum into the cervix and draw it backwards, while, at the same time, we make the pressure that has been indieated on the fundus. If it is imperative that the uterus should be made to clear the promontory of the sacrum in the unimpregnated condition, it is much more so when it contains the product of conception. Now, to make this manipulation, I turn the woman on her side, for by so doing the uterus falls into that position where it is offered the least resistence, that is to say, it is changed from holding a relation to the antero-posterior diameter of the pelvis to a position where it holds relations with the sacro-iliac diameter, which allows it more freedom of movement. Now I pass a tenaculum into the anterior lip aud draw backwards, while at the same time I push the fundus forwards, as already indicated. Over the tenaculum I pass a pessary, using Albert Smith's modification of the Hodge, and adapt it so that it will keep the uterus in the position to which I have restored it. Having restored the organ to its normal position, I instruct the woman that she must pass much of her time in the recumbent position, but not on her back, choosing any other position, for by lying on her back, she would favor the posterior displacement. She must keep particularly quiet about the time when her menstrual flow would have occnrred had she not been pregnant. If I were simply to push up this pessary it would probably do no good. It would be like thrusting a weazel into a hole and expecting him to find and kill a rat; he might do so and he might not, there might not be any rat in the hole. So with the pessary, you must first correct the deformity and then use the pessary that this correction may be maintained. This point is not borne in mind, pessaries are used carelessly, they are expected to do that which they can not do, and anathmas innumerable are hurled at them when they fail to accomplish that which they were never designed to do.
Now I make all this manipulation without exposing the woman at all; no exposure is necessary, for all that you have to see to correct this deformity, you can see with the “eye on the end of your finger.” This proceedure causes some pain, but this is a brave, plucky woman, who would submit to much more than this in view of the ultimate good that we hope and can almost surely promise to effect. You will generally do better in these cases if you can get along witout using a speculum. If she is not comfortable, she will come back and have the pessary readjusted. The pessary should always be removed between the third and a half and fourth months, for the uterus has then safely glided up past the promontory of the sacrum. Two weeks hence the time of her second missed period will arrive and she must then remain quietly in bed, and if the slightest symptom of uterine contraction occur, she will be given an injection of half a teaspoonful of laudanum in half a teacup full of water. In this way I think we can safely carry her through to the happy and desired termination of her pregnancy. I would strongly insist, in these cases, on the absolute necessity of forbidding intercourse. Some authorities even go so far as to say that the husband and wife should occupy separate rooms, that all temptation may be removed.
A few words more about pessaries. You will often find it necesseary to remove a pessary twenty-four hours after you have inserted it; these instruments are not designed to fit as accurately as false teeth, so that, while no one can wear the false teeth of another, one woman can wear the pessary of another, yet this is not desirable, for you should endeavor to make them so fit, that the woman is aware of the pressure of the pessary only because of the comfort that it gives and not on account of any pain or inconvenience which its wearing entails. To accomplish this you may have to try several times before you succeed. When you desire to mould the pessary to suit, to alter its shape, coat it with oil and pass it rapidly over the flame of a lamp (not slowly or it will burn), after a while you will notice that the surface looks a little less smooth, when you will find that you can bend it; now mould it to the desired shape and dip it in cold water which will fix it and you have it as you wish.
CANCER OF THE CERVIX.
Some six or eight months ago, I removed a cancer of the cervix with the thermo-cartery. The woman had a tedious convalesence, but finally recovered entirely and went home. You should always have such cases report to you regnlarly for examination, to see if there is any recurrence, once a month, if possible, and certainly not less often than once in two or three months. Well now, from this case I have learned a lesson.
The thermo-cartery has left so much cicatricial tissue, all the parts have been so contracted thereby that any future operation would be very much complicated. I used the thermo-cautery because the disease extended away up on the cervix and I feared that I could not well remove it all with the knife and scissors, the neck being entirely gone, but I believe now that I would have had a better result if I had used either the knife or the scissors.
THE OBVIOUS SIGNS OF CARCINOMA UTERI.
Here is a woman, forty-five years old, who has been married twenty-nine years. She has borne seven children and she says that her health was always good until one year ago. Then the first thing she noticed was apparently causeless hemorrhage from the vagina, which has continued nearly all the time, entirely independent of any exertion or any other obvious cause, existing at night as well as by day. It is said that nothing causeless can occur, but here the woman can give us no cause for this hemorrhage. She has no other discharge that she can differentiate from the bloody flux, which she tells us is very offensive. I ask her what it smells like, for sometimes the instinct of a woman will offer a better comparison than will the investigating words of science. This odor is sometimes compared to that of decomposing flesh. She complains of pain in one side, but none in the back. Well now we have here the obvious signs of carcinoma. I would not state a positive opinion without making a vaginal examination, but I am almost sure that when we do so, we will find cancer. When you have a history of causeless hemorrhage, with a bad odor, in a woman of this age, who is losing flesh, you always the best of reasons to suspect cancer. They are not absolutely diagnostic signs, but they are very nearly so.