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a judicial estimate of their value. It is, more
PATHOLOGY AND COURSE. over, essential to appreciate two other facts: Bacterial invasion and consequent infection First, the evidence on this most complicated may spread and may involve any or all of the question, although sufficient to lead to the
genito-urinary organs by either or both of two greatest apprehension, is not yet sufficient to es- routes: tablish definite and undeniable proof on the 1. By continuity of sursace or tissue. extreme side of the question; second, many 2. By the lymphatics or blood vessels. excellent clinical observers in private practice By continuity of surface the course is usually are disposed on the whole to qualify the danger upward from the vulva or vagina, through the of the situa:ion, and to conclude that it is vastly uterus and Fallopian tubes to the ovaries and underestimated. If the question involved peritoneum or through the urethra, vagina, matters only of scientific interest, their solution bladder and ureters to the kidneys. The would properly wait for further and more exact numerous glands of the vulva are strongholds observation. But the danger and duty of the where the virus may intrench itself and whence hour" is concerned with moral not scientific the constant supply may find its way to the problems, and the moral obligation is serious
organs above. enough to lead the writer to present it, even The vagina advantageously covered with from the ex parte standpoint.
pavement epithelium is relatively smooth, like "Why do large numbers of apparently healthy skin, and supplied with an acid secretion. young women date their pelvic infection from Bacteria, therefore, find lodgment there less the marriage week?" Is it, as one author easily than in ihe vulva. Moreover, the acid declares, the "fatigue and excitement of the medium is unfavorable to the culture of about wedding journey?" Why do so many women 90 per cent of all pathogenic microbes. This with perfectly developed reproductive organs also makes the vagina a difficult barrier to remain sterile from the time of marriage or pass. after the birth of a single child and a dangerous The uterus, although protected by these "child-bed fever?" The causation of too many anatomical and physiological conditions of the of such cases of hopelessly diseased uteri, tubes vagina, is itself especially vulnerable, on account and ovaries, not to mention proctitis with of the loose arrangement and thinness of its sometimes rectal stricture, urethritis, cystitis, epithelial covering the villous network of its pyelitis and nephritis, has been explained by arbor vitæ, the confluence and ramifications of the word idiopathic. Their histories, if written, its glands and the richness of its periglandular would often tell of an apparently cured gonor- and perivascular network By reason of these rhea before or after marriage in the husband. conditions the cervix uteri is adapted to receive, If the most destructive infection may follow retain and distribute infection. Were it not contact with a subject of gonorrhea after the for the tonic muscular contraction at the exdischarge has ceased, how perilous must be the ternal and internal ora and at the utero-tubat slight gleety discharge so often disregarded. constrictions, the frequency of infection of the Young men are sometimes advised to marry in endometrium, already great, would be much order to improve their sexual hygiene, and so to greater.5 cure an intractable chronic but "innocent" The Fallopian tubes are embryologically and gleet. Such advice may result in the destruc- anatomically continuous with the uterus, are tion of the reproductive organs of an innocent in fact, a part of it, and subject to the same woman. It is doubtless possible, perhaps not causes of infection. The ovaries and pelvic unusual, for gonorrhea to be so cured that the peritoneum in direct communication with the individual cannot transmit the disease. Failure, tubes may receive infection from below. Inhowever, to culuvate the gonococcus froni the fection by continuity of surface, however, urethral secretions does not prove its absence. although usually from that direction, does not So long as it can be cultivated marriage is always come from below; it may reach the prohibited. Repeated attempts should be made ovaries and pelvic peritoneum from above and in every suspected case. Marriage should be descend through the tubes, uterus and vagina deferred at least until after repeated efforts to the vulva. Tubercular infection, for exhave failed. A gonorrheal record does not ample, usually goes in his direction. necessarily settle but it always complicates the Infection by the Lymphatics and Blood question whether the individual may safely Vessels is undeniable in puerperal women. marry.
The trumatisms of parturition, often very extensive all the way from the uterus to the vulva, by way of the lymphatics or blood vessels, and may open wide the door for infection to be produce secondary infection of the pelvic peritransmitted by this way. The destructive toneum, ovaries, tubes and other genitalia. influence of the inflammation, phlebitis and Tubercular infection of the tubes, secondary to lymphangitis, on the vessels themselves may that of the lungs, is a familiar example. seriously and permanently impair the nutrition Experiment and clinical observation both of all the pelvic organs.
show that puerperal and non-puerperal infecThe route by co.itinuity of surface, save in tion may travel by blood vessels, by lymph puerperal cases, is generally accepted, and that channels and by continuity of surface. The by the lymph and blood vessels is often denied. relative frequency, however, of these modes of
If inlection is often transmitted from the transmission is a matter of speculation. Possibly genitals by way of the lymph vessels to the the route by continuity of surface is really a inguinal glands—the bubo is proof of this—it is superficial lymph route-that is, the infection evident that it may also travel by way of the may travel along the lymph channels of the lymph vessels a much shorter distance from the. mucosa. vagina or cervix to the parametria, perimetria
CLASSIFICATION, and tubes. This reasoning by analogy has Let us now raise a question relative to the been verified by experiment. Some observers, looseness and confusion of the current classifi notably Lucas Champonnier, claim that this cations. The term simple infection as distinis the more common mode of infection. Wert- guished from septic, for example, bas no strict hein, from experimental investigation on white pathological meaning. It is not yet settled mice, rabbits, dogs, guinea pigs, etc., concludes whether the so-called simple insection is aseptic that the gonococcus infection can pass through or whether it is only slightly septic. We know pavement epithelium and connective tissue, and that an inflammation seemingly very mild may thus reach and be carried by the lymphatic and readily take on a decidedly insectious character. vascular channels from the vagina or cervix to We may think of the infective or inflammatory the ovaries, tubes and peritoneum, producing process in several ways: (1) As having gone thus ovaritis, salpingitis and peritonitis. Giglio? only into the congestive stage; this would be a also experimentally demonstrated that infection mild forin. (2) As having gone on to the may travel from the vagina, cervix and bladder stage of effusion or suppuration.
(3) As to ihe broad ligaments, and may produce extra- being the result of a mild or virulent in tubal pelvic abscesses. He maintains that fection. (4) As occurring in structures of insection by the vessels is more frequent than greater or less resistance. What is there in by continuity of surface. When the latter such conditions to designate on the one hand occurs, he claims that it is more commonly in as simple, on the other as septic? In the presthe descending order from the tubes to the ent state of our knowledge we must use for uterus. This statement may have to be revised. descriptive purposes an adaprable and therefore
Continuous infection does not always mark flexible nomenclature. In this nomenclature the course of the microbes through the vessels. words like simple and septic can have only a They colonize at the points of least resistance, loose clinical significance. They cannot be hence the iubes may suppurate and the liga- u ilized as the outcome of scientific classificaments and ovaries go free. When, however, tion. We might simplify the subject by throwthe microbes travel by way of the mucosa, a ing out such words as simple. continuous inflammation is usual, though not A distinction between acute and chronic invariable.
inflammation, since these conditions enter Infection by the veins is specially common extensively into the pathology of the diseases in puerperal cases. It has often produced of women, is most important. Many deny general septicemia and pyemia through very altogether the existence of chronic inflammaslight lesions. The arteries also may carry tion, for example, of the endometrium. Some inlection. This is proven by the fact that attribute the condition which is usually classed bacteria have been found in paces where they under that name to congestion; others call it a must have been carried by the centrifugal circu- subinflammatory state. It may be well in passlation; for example, the gonococcus in the knee- ing to remark that an essential factor of inflamıjoint.: Hetero infection of the genitalia--that mation-round cells-is found in these chronic s, infection from without-s not the invariable conditions, and that they may the elore be rule. Diseased organs may send their germs properly classed as intammatory. We shall avoid the question whether certain conditions and lymph vessels of the pelvis and in the should be called congestive, inflammatory or cellular tissue of the pelvis. Sclerotic changes subinflammatory. The discussion of this in other organs, such as arterial sclerosis and question is long, tiresome and unprofitable, a interstitial nephritis, offer a close analogy. contest largely of words. The following out- It is unprofitable to speculate on the question line of some of the phenomena of inflammation whether the conditions just described under will help to make clear the distinction between the name chronic inflammation would better be acute inflammation and the conditions which classified as congestive or as subinflammatory are commonly grouped under the name chronic states. They are recognizable under either of inflammation.
these names. They occur more frequently in The inflammatory reaction which living tissue neuropathic women, and especially in cases of exhibits to morbid irritation is first defensive the various diatheses, anemia, lithemia, gout, and then constructive or reparative. The cholemia. Diabetes also is a strong predisposdefensive process is an effort to circumscribe ing cause. They are usually less dangerous to the disease by throwing around it a limited life and often more destructive to health than wall of exudate: the morbid action thus con- the acute infection. They constitute a large fined and concentrated within narrow limits, is proportion of the ailments of women and within those limits more or less intense or include some of the most distressing ailments, destructive. It may result in the sacrifice of a They are persistent and hard, often impossible, part for the safety of the whole. The force of to cure. In such cases it is often difficult to the disease is spent in the destructive process, draw the line between those congestions which and may be active only or chiefly within the tall short of inflammations and actual inflamlimiting wall. Finally normal conditions of mation. One of the most common forms of nutrition are re established, the constructive or so-called uterine catarrh is that which occurs reparative process becomes active and the limit- in women of deficient eliminative power; that ing wall is absorbed. If the constructive is, the bowels, kidneys and other eliminative process continues until repair is complete and organs fail to throw off sufficiently the waste then ceases, the part will resume its normal products. Under these conditions the mucous functions; the inflammation will be at an glands of the uterus, for example, whose funcend.
tion is not excretory, may vicariously undertake Acute Inflammation.-If the infection is of to make good the deficiency. An infinite such virulence or of such character as to call amount of misdirected and injurious local forth the defensive processes just described treatment is constantly being applied to the and to produce blood stasis, with more or less endometrium in such cases. severe swelling, pain, heat and redness and The significance of pelvic infection varies finally to produce local destruction, the infiam- according to the resistance of the patient, to mation is acute. The disease may terminate the location and nature of the structures inwith resoluuion or go on to suppuration.
volved and to the virulence of ihe causes which Chronic Inflammation.-If the irritation is of produced it. Strong predisposing causes make minor intensity, or in any other way of such the women less able to resist morbid irritation, character as to fall short of provoking much and infection once established is more likely to defensive action, there will be little or no limit- be severe and progressive.
If infection is coning wall, and consequently no intense destruc- finec superficial areas, its gravity is relatively tive process concentrated within a circuin- much less than when deeper structures are scribed space; heat, swelling, pain and redness diseased. Endometritis, for example, is less if present will be nore diffuse and less pro- serious than an inflammation involving the nounced. Under these conditions there is a parametric lymphatics and veins. Moreover, minimum of desense and an excess of construc- the same infection may be somewhat more tion, and the inflammation is chronic.
serious in some places than in others. This Chronic inflammation may follow acute may be illustrated by the case ol a inan who inflammation, or may have been sub-acute or picked his teeth with a vaccine point and chronic in the beginning. The excessive con- experienced most distressing result. Some structive action which belongs to it explains bacteria are useful, some harmless, and some the hyperplastic and hypertrophic results of only mildly virulent. The gonococcus, for so-called chronic metritis. It also explains example, is more general and therefore more certain morbid nutritive changes in the blood disabling than the staphylococcus. The strepto
The treatment requires the individualization of each case. So far as it is possible to indicate the treatment in general, it is prophylactic. It therefore includes hygiene, sexual and general, and especially it includes aseptic midwifery. Systemic measures, quite generally neglected, should have close attention. Many cases which pass as gynecological really belong to the wider field of internal medicine.
1617 Indiana Avenue.
coccus pyogenes is more dangerous than either.
From the foregoing it is easy to explain why an infection, even in the deeper structures, if not from very destructive bacteria, may present in the more acute stages most of the subjective and some of the objective appearances of a fatal disease, and yet after a few days terminate in a complete return to health. The reason is also obviods why a superficial vulvar infection, apparently innocent, may be the result of a gonococcus or of a streptococcus invasion, and may ty continuity of surface or by way of the lymphatics or veins finally destroy life or render it miserable and useless.
DIAGNOSIS AND PROGNOSIS, The symptoms are often utterly disproportionate to the lesions. An infection of little danger may cause the greatest misery; another which directly threatens life may be almost painless. Objective examination should, therefore, especially in acute cases, be thorough. The subjective symptoms may be misleading. The prognosis depends upon the region infected, the general and local resistance of the patient and the nature and extent of the infection.
Steinschneider, Berliner klinische Wochenschrift, 1887, No. 173; Pozzi, page 158.
2 Nöggerath. Latent gonorrhea, Trans. Amer. Gyn. Society, Volume 1, page 268, 1876.
* Sänger. Ueber die Beziehung der Gonorrhöuchen. Zu Infektion zu Puerperal Krankungen Verhandlungen der Deutschen Gesellschaft für Gynäkologie. Leipzig, 1881,
+ Lomer. Deutsche medicinische Wochenschrift, No. 43. 1885
• Bonnet & Petit, Traité Pratique de Gynécologie, page 145
* Paris Sur zical Society Transactions, December, 1888; New York Merical Journal, March 22, 1890.
? Giglio. Annali di Obstetricia e Ginecologia, May and June, 1893.
* Luther. Sammlung Klinischer Vorträge, 1893.
PHYSICIANS AND APOTHECARIES IN PURITAN NEW ENGLAND.
BY HERBERT C. VARNEY, ST. PAUL, MINN. • Of physicians and apothecaries in early New life in a new country, he could not endure the England it may almost be said that for the first hardships of his new surroundings, for his death hund ed years there were none; that is, in the is recorded at Charlestown in September of the sense of the word as we understand it.
same year. John Dean, or as he styled himself It must not be inferred from this, however, "John Dea a Chirurgeon," was an early physithat our Puritan forefathers were without cian of Ipswich, Mass. He died in 1648. His medical attendance; far from it, but the physi- son, Philemon Dean, was one of the early cians in those days were the ministers; these physicians of his native town, renowned both were men of education and learning, nearly all for his skill in medicine and for his standing in of them being graduates of the University of the meeting house. His gravestone, with its Cambridge in England, and those of a later quaint Puritan epitaph, still stands in Ipswich. date of Cambridge in New England.
** Here lyes ye body of Doctor Philemon Dean who Many of them had been ejected from their
died October ye 18th, 1716, aged 70 years. livings for non-conformity, and some of them
O Lord, by sad and awsu:1 stroaks, had taken up the practice of medicine to obtain
Of man's mortality;
O let us all be put in mind a living. Others, after coming to this country,
That we are born to dye. in order to support themselves—their pastoral
Grave saint behind that cannot find, salaries being insufficient-studied a few med.
Thy old love night or morn. ical books, and then ministered to their neigh
Pray look above, for there's your love bors in both spiritual and temporal things. It Singing with ye first born." was in the hands of such men that the practice The last two lines of this stanza were quite of medicine wis placed for nearly the first popular among Puritan epitaph makers. hundred years of New England's history.
Another famous physician of Ipswich was The first New England physician of whom I Dr. Thomas Wells, more often spoken of in the find any record is Dr. William Gager, who old records as Deacon Wells. He died in 1666. came out in the spring of 1630, probably in the By his will he left to his son "phissic bookes" same feet with Winthrop. Not being used to valued at about nine pounds.
Some of the early physicians who came to harmless, such as anise seed and liquo:s, yet New England found the practice of medicine they had extraordinary and violent effects. but a "meene help,” at least Giles Firmin of 3. She told those who would not use the Boston lound it to be such. He came in 1633, "physicke" that they would never get well, and is spoken of in the records as a "godly and accordingly their diseases continued, con. man, an apothecary of Sudbury in England." trary to the efforts of the physicians and surIn an account of his life written by himself he geons. says: "being broken from my study in the 4. She had the witches' marks. prime of my years, from eighteen to twenty- In spite of her protestations of innocence, eight, and what time I could get in those years, poor Margaret was hanged as a witch on I spent in the study and practice of physick in Boston common in 1648. Those were the days that wildernes:." The wilderness afforded when this law was on the statute books: “If him but a very "meene" living, for in a few any man or woman be a witch, that is,
hath or years we find him back in England again, and consulteth with a fainiliar spirit, they shall be exchanging the profession of medicine for that put to death." of theology, when he became quite a noted
Almost without exception in all the early setminister. He has left one tribute to his early
tlements of Massachusetts and Connecticut the New England neighbors which is worthy of practice of medicine was carried on to a greater repetition. Before a meeting of divines held at or less extent by the ministers. This union of Westminster in 1654 he said: "I have lived in medicine and religion was called by Cotton a country seven years; all that time I never Mather “an angelic conjunction.” The first heard one profane oath and all that time never
medical treatise published in America was by did I see a man drunk.”
of these minister physicians, Thomas The most famous of the early physicians of
Thatcher, and is entitled “Brief Rules for the
Care of the Small Pocks,"1677. Bosion was Dr. John Clark, who had also settled for a time at Newburg. He was the
Probably the most famous minister-physician first physician in this country to perform the
was the Rev. Michael Wigglesworth, who was operation of trepanning the skull. Dr. Clark
born in Yorkshire, England, October 28, 1631, died in 1664, aged sixty-six years. He had a
and was brought to this country when a very son, also a doctor, who was one of the early
young child. He entered Harvard College in settlers of Rhode Island.
1617, and graduated with the class of 1651. James Minoit was a physician a: Concord,
After his graduation he was appointed a tutor and from the inscription on his gravestone
at the college, and during that time prepared
himself for the ministry and was ordained must have been a little of everything else.
minister at Malden in August, 1656. After his "Here is interred the remains of James Minott,
ordination his health became so poor that he Esq., A.M., An excelling Grammarian, Enriched
had to spend some time abroad, and was never with the gist of Prayer and Preaching, a commanding Officer, a Physician of great Value, a great
of a very strong constitution. For nearly fifty lover of peace as well as of Justice, and which was
years he served the church at Malden faithfully, his greatest glory a Gentleman of distinguished
both as minister and physician, as Corton Virtue and Goodness, happy in a virtuous Posterity, Mather said of him, “lively unto death.” He and living Religiously died Comfortably, Sept. 20, died in 1705. Wigglesworth will always be 1735, aged 83 years."
remembered for his production of that sulphurThe first women who tried to engage in the
ous poem, the “Day of Doom," which was very practice of medicine in Massachusetts do not popular in its day, and also of a book called
"Meat Out of the Eater.” An extract from seein to have met with very good success. The famous Anne Hutchinson tried her hand at
the “Day of Doom" may be interesting. The medicine, but on account of her religious opin- following is one describing the punishments of
hell: ions was banished from the colony. Another,
“For day and night in their despite, Margaret Jones of Charlestown, was indicted
Their torments smoak ascendeth; and found guilty ul witchcraft upon the follow
Their pain and grief have no relief, ing evidence:
Their anguish never endeth; 1. She was found to have a malignant touch,
There must they ly and never dy so that whosoever she touched were taken with
Tho' cying every day; deafness and vomiting.
There must they dying ever ly 2. She prac iced ; hysic; her medicines being And not consume away."