PART IV.

ETIOLOGY IN GENERAL.

THE causes of gynecological diseases may be divided into predisposing and exciting.

Predisposing Causes.-The first class, although more remote in their effect, are more important on account of their frequency. Heredity may play a double rôle, either that the same defect that is found in the mother is transmitted to her daughter, especially malformations and malignant diseases, or that the child inherits a generally weak constitution from one or both of her parents, which, in combination with her sex and the other predisposing factors, gives rise to diseases of the genitals and pelvic organs. In the latter respect it must be noted that children of parents advanced in life at the time of their procreation as a rule are less vigorous than those engendered in younger years.

Education has great influence in the development of gynecological diseases. Too great assiduity in study in early youth concentrates the nerve-energy on the brain, and deprives the uterus and ovaries of their share at a time when these organs are undergoing an enormous development, and preparing for the important functions of womanhood and motherhood. Too great interest in and practice of music, by its profound effect on the emotions and the constantly repeated physical thrill in the nerves, is particularly dangerous.

Everything that causes active or passive hyperemia of the pelvic organs is a source of disease. In this category belongs sexual excitement brought on by reading prurient novels; by looking at obscene pictures; by seeing representations on the stage that aim at the exposure of so much of the body as existing laws and public opinion will permit; by masturbation, sapphism (the same as tribadism), sodomy, and even normal coition if performed too violently.

The neglect of the skin, by which a chief emunctory is nearly blocked up, is hardly found in the better classes in this country, but is exceedingly common among the poorer women, especially immigrants, of certain nationalities.1

Insufficient exercise and lack of open air are a frequent cause of disease, and favor the stagnation of blood in the pelvis; but in this

The Jewesses from Russian Poland in my dispensary experience exceed all others, and make, in fact, the impression of never bathing or washing their body.

respect, as also in regard to food, a great change has taken place in the higher classes during the last decade. The ideal of the American girl is no longer to be thin and pale. The young men having taken an ever-increasing interest in athletics and all sorts of sports, most of which are cultivated in the open air, the girls do not want to stay behind. The dull croquet has speedily been followed by the lively tennis; muscular strength is developed by swimming, riding, fencing, skating, and ballet-dancing; and now the girls begin even to have gymnasiums of their own, where every part of the body may be developed by properly adapted exercises.

In regard to food there is also great improvement, but it is too often necessary to inculcate the importance of taking a proper amount of good, wholesome nutriment. Many girls have a loathing for food in the morning, and will, if allowed to do so, go to school with an empty stomach, and let their brain work for hours before they take any substantial food. A very bad habit, that spoils the appetite, causes a sour stomach, and in consequence impoverishes the blood and gives rise to nervous troubles, is the immoderate use of candy, which among women and children corresponds to alcoholic beverages and tobacco in

men.

A fruitful source of disease among women is the lack of attention to the excretions. The vast majority of gynecological patients suffer from constipation. They will go for days-nay, sometimes a whole week-without a movement of the bowels. This accumulation of feces gives rise to local trouble by pushing the uterus out of its place and interfering with the free circulation of the blood in the pelvis; but, besides, it causes absorption of the gaseous and liquid part of the fecal material, that shows its deleterious effect in bloodless lips, headache, neuralgia, and fatigue. The excretion of the urine is no less neglected. The requirements of polite society will often prevent women from emptying the bladder in time, which may lead to paralysis of that organ, not to speak of rupture, and not unfrequently is the cause of cystitis and neuralgic pain, besides predisposing to uterine disease by pushing the womb out of place.

The mode of dressing, although changing under the varying caprices of fashion, is always fundamentally wrong and conducive to disease. The "décolleté" evening dress and the bell-shaped nether garments drive the blood from the periphery to the pelvis. The lower part of the abdomen is generally insufficiently protected from cold air and blasts of wind, which become particularly dangerous to women who skate. High heels, when worn at an early age, while all articulations are yet subject to change, not only alter the shape of the foot, but are apt to cause neuralgia in the legs and a change in the inclination of the pelvis and the normal curvature of the back.'

1 S. Busey, Trans. Amer. Gyn. Soc., 1882, vol. vii. pp. 243–261.

Of much greater importance yet is the use of corsets. Even a loose corset exercises a pressure of 30 pounds, which has still greater effect on the abdominal cavity than on the thoracic. The abdominal wall is thinned and weakened. In the erect posture the liver and intestines are pushed forward, driving the weakened abdominal wall in front of them, and in sitting the normal pressure backward from the abdominal wall against the spinal column is changed into one going directly down into the pelvic cavity. By tight lacing the pelvic floor is bulged down to the extent of one-third of an inch.'

Late hours, social gatherings beginning at the time when the girl ought to go to bed, have very bad effect on the nervous system, and predispose to much greater suffering from actual trouble than is felt by those leading a more natural life.

Neglect during menstruation seems to be a fruitful source of female complaints. Women not only move about, but dance and skate, at a time when a process is going on that is so easily turned in an abnormal direction.

We have seen in the chapter on Physiology how differently women are constructed from men in regard to sexual excitement. It is very unlikely that the mere frequency of normal sexual intercourse does a healthy woman any harm, but it is quite different when the natural relations are disturbed. The sin of Onan, sodomy, and even the use of condoms, injections made in a hurry immediately after ejaculation at a moment when nature calls for rest, and often with a fluid of improper temperature, all cause a tension of the nervous system and a congestion of the genitals which in the course of time result in hemorrhage, leucorrhea, chronic metritis, fibroids, or other affections. Marriage with existing disease of the pelvic organs often lays the foundation of much wretchedness for both husband and wife. If a flexion of the uterus may be cured by childbirth, provided conception takes place in spite of it, how different is it when the ovaries or tubes are the seat of chronic inflammation, which causes excruciating pain at the mere touch during a careful examination!

If married life has its dangers, celibacy does not offer entire protection. Especially is the liability to the formation of fibromas of the uterus greater in unmarried and nulliparous women than in those who have borne children, as if the uterus, deprived of the function of building up a new being, were more liable to use the material for the formation of a tumor.

The question of the effect of the corset and other wearing apparel has been ably discussed by Dr. Robert L. Dickinson in the New York Med. Jour., Nov. 5, 1887, Hare's System of Therapeutics, vol. iii. pp. 730-784, and Trans. Amer. Gyn. Soc., 1893, vol. xviii. pp. 411-433.

'A careful perusal of Genesis xxxviii. 9 will convince the reader that thereby is not meant the vice which erroneously has been named after that man, and which properly is called masturbation, but the practice commonly known as withdrawal."

P. S. BRIQUIERE, M. D.

In married as well as unmarried women the climacteric predisposes to disease-a point which has been considered in a previous chapter (p. 124).

Exciting Causes.-Sometimes a faulty development of the fetus constitutes directly a disease. Too great closure of the two halves forming the body gives rise to atresia; too little results in hypospadias, epispadias, or extroversion of the bladder. Arrest of development may also cause an infantile uterus. The genitals may be more or less completely absent. These conditions will be discussed under the diseases of the special organs.

Coition during menstruation has often been the cause of retro-uterine hematocele.

Childbirth is a fruitful source of disease to women, sometimes without, but oftener with, fault on the part of the obstetrician. Tears of the vaginal entrance often lay the foundation of prolapse of the vagina or the uterus. A torn cervix gives rise to ectropion of the mucous membrane, leucorrhea, hemorrhage, cystic degeneration of the cervix, secondary sterility, neuralgia, impaired nutrition, and carcinoma or sarcoma of the uterus. Too early rising after confinement, while the uterus is still large and soft, often causes subinvolution or displacement of that organ.' Through deficient antiseptic precautions inflammation is started in the uterus, the tubes, the connective tissue of the pelvis, or the peritoneum-conditions which, if they do not end the patient's life at once, often leave her sterile or a sufferer for life.

Abortions, spontaneous or legitimately induced to avert greater evil, may give rise to conditions calling for the gynecologist's interference; but of by far greater importance is the criminal abortion so frequently resorted to by women in all classes of society, in the country as well as in cities. Sometimes the ignorance and recklessness of the abortionist go so far that he makes a hole in the uterus through which one can put one's thumb, and through which the intestines may find their way into the vagina and down between the thighs; and it is by no means rare to read in the reports of coroners' autopsies in suits for malpractice that wounds inflicted with some sharp or pointed instrument are found in the genitals of those who have succumbed in consequence of criminal abortion. But, even apart from these surgical injuries, there are two immediate dangers of abortion— namely, hemorrhage and septicemia, which are due to retention of the whole or part of the ovum. Hemorrhage occurs in two forms: either in the shape of sudden considerable flooding or as a constant or frequently-repeated loss of small amounts of blood, which is due

1 This question has been considered at length in my article "Rest after Delivery," Amer. Jour. Obstetrics, vol. xiii. No. iv. Oct., 1880, pp. 851-863.

2 Cases of this kind were reported by Thomas and Noeggerath in the Obstetrical Society of New York, Amer. Jour. Obstet., 1882 (Supplement, pp. 4-6).

to fungosities of the endometrium, and undermines the most robust constitution.

The more remote effects of abortion are similar to those of too early rising after childbirth, especially subinvolutions and displacements.1 Gynecological Treatment.-Unfortunately, our list of the chief direct causes of gynecological diseases would be incomplete, if we left out the gynecological treatment itself. Even with the greatest care, our procedures are frequently not free from danger, and, if we neglect antiseptic precautions, the danger increases manifoldly. Especially is all intra-uterine treatment with sounds, curettes, tents, dilators, and pessaries fraught with danger on account of the absorption of septic material, which so easily takes place through the lymphatics of the endometrium.

Gonorrhea.-Greater than any other danger is, however, sexual intercourse with a man who has gonorrhea, or who has, perhaps, had one many years ago which has not been thoroughly cured. While a gonorrhea in man in most cases is a trifling disorder, although exceptions, in which it leaves a serious condition, and even becomes fatal, are not so very rare, in women it is one of the most serious diseases. If it only affects the vagina and the urethra, it is of less consequence. It is already more serious if it extends into the vulvo-vaginal glands, but if it works its way up through the uterus to the tubes, ovaries, and pelvic peritoneum, it jeopardizes not only the woman's life, but, if she survives, she is most frequently left sterile, and is often an invalid for life, being subject to a chronic inflammation of the tubes and ovaries, with frequent acute attacks of peritonitis and an incurable uterine catarrh due to reinfection from the tubes. If sterility does not follow, such women often have an attack of puerperal endometritis in every confinement.

Under the name of latent gonorrhea has been described a condition in which a woman is infected by a man who had a gonorrhea months or years before. No acute gonorrhea is produced, but the women become ailing, remain sterile, and are affected with chronic, subacute, sometimes acute, very often relapsing, inflammation of the internal genitals.3

An interesting paper on Abortion and its Effects" was read by Dr. J. T. Johnson of Washington, D. C., before the Medical and Chirurgical State Faculty of Maryland, on April 23, 1890 (Maryland Med. Jour.).

Garrigues, "Danger of Stem Pessaries," Amer. Jour. Obstet., Oct., 1879, vol. xii.

p. 756.

3 Emil Noeggerath, "Latent Gonorrhea," Trans. Amer. Gyn. Soc., 1876, vol. i. p.

268, et seq.