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much distress and inconvenience that he was not able to attend to his business. He was put on ecthol in doses of teaspoonful every three hours, and the same remedy was applied locally. In ten days this patient had no further attacks of itching and the local lesions were healed. He was told to continue with ecthol for ten days longer, however.
C. W., aged eleven, had eczema on his hands. This annoyed him so much that he could not handle his school books without pain, and his school-fellows avoided him, thinking he had the itch. Ecthol, used internally and locally, acted promptly, and in two weeks my patient was able to go back to school without any marks of the disease which had been so troublesome.
Mr. E. B., aged thirty, had eczema on arms, hands and chest and was an intense sufferer. I put him on the treatment, a teaspoonful of ecthol every three hours, and the same remedy applied locally every four hours. This treatment was satisfactory to the patient, and the disease speedily disappeared. He was fully well in three weeks after he began the treatment.
It must be confessed that in spite of the efforts to throw light upon this subject through studies in the physiclogy and pathology of ovulation and menstruation, assisted by observations in the laboratory and at the operating table, our knowledge of the more hidden causes of sterility is still elementary.
The family physician, wearied by the importunities of young married women, who seek to know the reason why they are childless, refers them to the gynecologist, with the hope that the latter will be able to discover some explanation that has eluded him. Too often the specialist is obliged to acknowledge frankly his own limited knowledge, or, if less candid, suggests possible causes and remedies with a confidence which he is very far from feeling. I have been led into this train of thought by my experience during the past few months, when it has seemed as if hardly a week had passed without my being questioned by some woman who desired an opinion upon this subject: why she had never conceived, and could any. thing be done to secure the desired result. There was nothing especially interesting about any of these cases; they are sufficiently familiar to us all, yet, taken as a whole, they furnished me with a forcible commentary on the limitations of modern science, and of gynecology in particular.
The results of my examinations were various. In some cases I could find absolutely nothing to account for the sterility, in others I suspected some hidden cause. In a few, the prognosis was absolutely bad, in others more encouraging. In a few I could hold out some hope from operative procedures, or, again, the same operations had already been performed without results. With few exceptions there were more or less marked pelvic symptoms, as constant pain or dysmenorrhea, The periods of sterility varied from one to ten years, or the patient had aborted after marriage, and had not conceived since. Examples of “one-child" sterility were not wanting.
In no class of cases have I found women more desirous of a dogmatic opinion, or more willing to grasp at any prospect of cure by operation. I know of no stronger temptation which besets a gynecologist
[Written for the MEDICAL BRIEF.)
Prognosis in Sterility.
BY HENRY C. COE, M. D., Professor of Gynecology in the New York University and Bellevue Hospital Medical
College. New York City.
Some apology is necessary for introducing a subject of which so much has been written that it would seem to have been worn threadbare. My excuse is that it is one that has always been of vital interest to the profession, and will continue to be a burning question until the end of time. Its importance is attested by the flood of literature that has been poured out-monographs, extended chapters in text books, journal articles, society discussions; in fact, every gynecologist has had something to say about the “cure of sterility."
than that to yield to the patient's importunity, even against his better judgment. Early in his practice, fresh from lectures and text-books, a man is apt to be quite enthusiastic about the treatment of these cases. Most of you recall as students the vivid word-pictures of Thomas, from which we gained the idea that incision of the cervix and the insertion of the intrauterine stem was a sure cure for dysmenorrhea and sterility. This was in a line with the teaching of Sims, whose classic on "Uterine Surgery" exerted such a powerful influence on succeeding teachers and surgeons, an influence which is still felt, as shown by the general belief in the purely mechanical theory of sterility.
It is a curious fact that while gynecology has made such strides in other directions, especially in abdominal surgery, we still keep uppermost in our minds the 'idea that cervical stenosis is the main cause, forgetting the more important conditions within the abdomen. We still dilate, incise, insert stems, straighten the uterus, and have a complacent feeling that we have met all the indications. Is this crude treatment in a line with modern scientific researches?
The proper investigation of a case of sterility is no light task. We must divest ourselves of personal prejudices, and endeavor to be absolutely unbiased by the opinions of previous consultants. Let us take the most difficult example first. A young woman is referred to us who has been married, say five or six years, and has never conceived. To our first question she replies that she has always been well, and can not recall any pelvic trouble aside from moderate dysmenorrhea.
Her periods have been regular, and marriage has not brought any new pains troubles. Her husband is healthy, marital relations are satisfactory, or at least pain. less, and her own health is perfect. Her only complaint is sterility. More direct questioning reveals facts, unimportant to her, but not to the examiner. She is led to recall some passing indisposition soon after marriage-a slight attack of abdominal pain and tenderness, perhaps at the time of menstruation, confining her to her bed for a few days, usually diagnosed
as "congestion of the ovaries.” She may have missed a period
and then flowed profusely, or possibly had a vaginitis more or less severe, and attributed to "cold” or sexual excess; or, during the first year or two after marriage various methods were adopted to prevent conception. The result of the examination is negative, perhaps a slight anteflexion, an undeveloped cervix being found, a moderate leucorrhea, but no tenderness on palpation over the uterus or adnexa.
With a proper regard for the natural delicacy of the patient, we ask for an in. terview with the husband, and are more searching with our questions, going into his own history ab initio.
We may assume that his earnest cooperation is obtained, and that he conceals nothing (there are such cases). He can remember no so-called "youthful indiscretions," and is perfectly capable sexually. A further test is the examination of his semen. This, by the way, is seldom done in this country, in spite of the recommendation in every text-book. We are more squeamish than foreign patients and phy. sicians. Curious facts are often noted in this connection. On several occasions I have found complete azoospermia in the husband, when I was about to dilate the wife's cervix for the cure of sterility. Doubtless there are many cases in which the unfortunate wife is made to suffer for the sins (or misfortunes) of her partner. This is a disagreeable subject for investigation, but surely it is quite as legitimate as the examination of any other se. cretion, or excretion, of the body.
In the face of this negative evidence we would seem to be justified in regarding the case as one in which there was a want of so-called "mutual adaptation,” and may dismiss the patient with the rather doubtful consolation that time may yet bring about the desired result. This may satisfy some women, but after several months of fruitless endeavor, they return for more information. Although there is no satisfactory evidence that the endometrium is diseased, we can find no other explanation for the sterility, and suggest curettement, which is readily acceded to. The curette removes, perhaps, a few granulations, but not enough to justify the diagnosis of hyperplastic endometritis. Under these conditions, in my
opinion, the prognosis is uncertain. I have been waiting several years for results in two or three such cases.
Far more common is the class in which we are led to infer from the history that in consequence of early sexual excess the prevention of conception, or a mild grade of gonorrheal infection, the endometrium is in such an unhealthy state that conception does not occur, or if it does, the ovum is cast off in a few days. I believe that many women who give a history of menstrual irregularities really conceive, and abort a week or two after the expected period. They usually present the ordinary symptoms of endometritis, profuse leucorrhea, so-called “congestive" dysmenorrhea and menorrhagia. Frequent or excessive intercourse at the time of the period is undoubtedly a potent factor in causing the accident. Here curettement offers a fair prospect of cure, or at least renders conception much more probable, especially if the patient is separated from her husband for a time, and matrimonial relations are properly regulated.
When there is an obscure history of latent gonorrheal or mild septic infection following an early abortion (spontaneous or induced) the prognosis must always be somewhat doubtful, as there is a possibility that the distal ends of the tubes may be occluded, though there may be no symptoms or signs leading one to suspect this. We so often find this condition (in fact extensive pelvic adhesiors) on opening the abdomen, that we can place little dependence on the clinical history as an aid to diagnosis.
Sims laid a good deal of stress upon the presence of an acid discharge from the uterus as a bar to impregnation. Experience has shown that it is not the discharge, but the diseased condition of the endometrium, which is the real obstacle. The mere presence of a plug of thick mucus in the cervix certainly does not justify one in deciding that this is sufficient to prevent conception. When we recall the frequency with which women conceive with advanced carcinoma and extensive erosions of the cervix, we can not regard a cervical discharge as so important.
An interesting class of cases, of which I have seen half a dozen examples within
the past two years, includes women between twenty-five and thirty-five, without any history or symptoms of pelvic disease,
ave remained sterile for several years, although menstruating regularly and without pain. They state that during the past year or two they have in. creased rapidly in weight, and at the same time the menstrual flow has become scanty and irregular, sometimes ceasing entirely, yet without the ordinary disturbances attending the climacteric. The direct relation between ovarian activity and the processes of nutrition has been repeatedly demonstrated, experimentally as well as surgically. The increase in adipose after the normal and artificial menopause is sufficiently familiar. While there is undoubtedly marked diminution of the functional activity of the glands in these cases, we can not infer that ovulation ceases because there is no menstrual flow. Experience has shown that when these patients succeed in reducing their weight, say thirty or forty pounds, the flow often returns. One woman told me that she menstruated regularly, and even profusely when undergoing treatment at Marienbad, but since she returned her menses have not reappeared, while she has regained her former unwieldly bulk. In another case the patient menstruated only three or four times a year, but under the rigid diet and hard training which she has since pursued she had been regular for three years.
I have never found that drugs, local faradism or galvanism, or treatment applied to the interior of the uterus does the least good in these cases. Reduction of weight offers the only prospect of relief. Certainly any operative procedures would be worse than useless. I have not had such results from the use of thyroid or ovarian extract as have been anticipated. The prognosis as regards the cure of sterility in such cases is naturally unfavorable, and one must need be cautious about promising such a result, even if the periods return with more or less regular
True cases of premature menopause undoubtedly occur, though some writers are skeptical with regard to their physiolog. ical character, believing that they are is necessarily an unfavorable element in prognosis, provided that the patient has always possessed this peculiarity, and that they do not result from any pathological condition. Should they develop after marriage, in consequence of some attack of inflammation, the prognosis would depend upon the severity of the local lesion and the possibility of curing it.
(To be continued.)
I have been reading the BRIEF most of the time for thirty years and do not want to be without it, believing it to be one of, if not the best, journals printed for the money. Enclosed find one dollar for the BRIEF.-A. L. WEBB, M. D., Box, Ala.
[Written for the MEDICAL BRIEF.)
Can Catarrh Be Oured.
BY CLARENCE C. RICE, M. D.,
really instances of premature atrophy of the uterus. I recall three in women under twenty-eight, all of whom became enormously stout within a few months. The menstrual nisus was entirely absent and there were no pelvic symptoms. Their uteri were not atrophied. Prolonged treatment, reduction of weight (thyroid was persistently used for months in one instance) were entirely without results.
In one instance I had an opportunity to study the condition of the ovaries. The patient, aged thirty-five, had been married five years, and had never conceived. During that period she had "suffered many things of many physicians”—repeated curettements, local treatment under different specialists, electricity, treatment at foreign spas, etc. Her periods had entirely ceased two years before, without distinct climacteric symptoms except increased adipose. She was exceedingly neurotic, and had always suffered from vaginismus and persistent pain in the left side, extending over a period of fourteen years. There was an obscure history of recurrent attacks of pelvic peritonitis. I examined her under ether with her physician, who had assisted at five or six similar séances, obtaining as many different opinions. By recto-abdominal palpation, I was able to map out easily an atrophied uterus not larger than my thumb. The ovaries could not be felt. I gave it as my opinion that the pain was probably due to old adhesions, and advised an explorative incision.
After my examination I was told that my opinion coincided with that of another gynecologist. One gentleman had said that there was nothing the matter with the patient, and an eminent specialist had guaranteed that he could cause a return of the menses by dilating the cervix and making applications to the interior of the uterus. After much further discussion, the abdomen was opened, and extensive intestinal adhesions were found on the left side, as was prophesied. The ovaries and uterus were completely atrophied, corresponding in appearance to the organs in an old woman. The folly of promising a return of ovulation and menstruation under such conditions was self-evident.
It may be stated in general that neither scanty, nor profuse, menstruation in itself
Professor of Diseases of the Nose and Throat,
New York Post-Graduate Medical School and Hospital; Consulting Surgeon in Throat Diseases to the Out-Door Department, Bellevue Hospital; Visiting Physician New York Infant Asylum; Laryngologist to the Montefiore Home; Fellow of the Academy of Medicine; Member of the New York County Medical Society, State Medical Society, Pathological Society, American Laryngolog. ical Association, Etc., Etc. New York City.
The nose and throat specialist, as well as the general practitioner, is still being asked this question by patients in all conditions of life. The older specialists can distinctly remember the dread with which they considered a proper reply to such a question. The conscientious physician was very much opposed to giving a de. cidedly affirmative answer, because frequently recurring coryzas always delayed the success of nose and throat treatment; nor was he willing to state that he was unable to treat successfully catarrhal cases, because he felt that it was obligatory upon him to do so, and he was confi. dent that the ttime was fast approaching when a better knowledge of the pathology of nose and throat diseases would suggest the proper methods of treatment which would surely relieve the troublesome symptoms which accompany the different varieties of nasal disorders.
A "cold in the head” very closely resembles the active symptoms of catarrh, and the old method of treating nasal catarrhs, by washing the nose with an alkaline spray, and following this with an application of some form of an astringent applied by atomizer or applicator was pretty promptly followed by an acute coryza, which aggravated rather than lessened the catarrhal symptoms, and baffled all the attempts of the physician to "cure" his catarrhal patient.
We may say, in a very general way, that nasal catarrhs may be divided into two classes. The hypertrophic moist variety, characterized by swellings and enlargements of the soft tissues and cartilaginous and bony prominences and spurs of the hard tissues; and the other large class known as the atrophic or dry variety of nasal catarrh, presenting many degrees of shrinkage of the tissues and dryness of the mucous membrane.
Colds in the head are the great cause of the hypertrophic or moist variety, therefore, if "colds in the head," or more properly speaking, acute coryzas, can be prevented by placing the nose and, perhaps the whole general economy of the patient in proper condition, then it is fair to assume that catarrhal swellings and hypersecretion can be gradually diminished and controlled until the patient is no longer susceptible to colds. The successful proposition is, therefore, to put the nasal passages in such condition that they are no longer susceptible to acute catarrhal inflammations. The patient being immune to the agents which produce acute catarrhal symptoms, his chronic catarrh will permanently disappear.
This leads us to consider the abnormal or pathological conditions of the nose, which predispose to acute colds or coryzas.
1. We may state that the nasal mucous membrane of neurasthenic, anemic people is much more sensitive to external irritants than that of vigorous robust patients. Sudden change of temperature, the chilling of the body, wetting the feet, exposure to dust and dirt, acute indiges
tion, will, in these sensitive people, produce an acute coryza, because the mucous membrane is so hyperesthetic, whereas, in stronger people, the same conditions may have no effect whatever.
Can catarrh be cured in what we may style the catarrhal class of patients? Yes. By rectifying two conditions.
1. Improving the general condition of the patient.
2. Rendering the nose immune to external irritants.
We will now consider the general treatment of the patient, as the administration of tonics, electricity, cold baths, general massage and vibratory massage of the nose, although we consider these most important, and do not advise local treatment of the nasal passages without such proper attention to the general health.
Before stating the agents which will shrink or destroy any portion of the tissues of the nose, we wish to say that they should be applied only by the skilled phy. sician, who understands, too, the possibil. ity of converting by over-treatment a hypertrophic or moist catarrh into that form which is more troublesome to the patient, and much more difficult of cure, viz., the atrophic variety. In the hands of the skilled physician, sensitiveness of the na. sal mucous membrane can be very much diminished, and soft enlargements reduced by the application of some form of mineral acid. It is much better to apply the acid over a too limited rather than too great surface, and at too little rather than at too great depth. It is wise to wait sev. eral weeks after an application of chromic acid to the turbinated tissues, to determine whether the application has fully accomplished its object, viz., the contraction of the swellings, the lessening of the sensitiveness, and the diminution of se. cretions. There is a nice point of balance between the curing of a moist catarrh, and the causing of a dry one, which the ex. pert rhinologist learns only after years of experience. Chromic acid fused on an applicator should be pushed into the hy. pertrophy at one small point, and not al. lowed to destroy the mucous covering.
There are other methods of reducing hypertrophic swellings in the nose, and removing nasal sensitiveness than by the application of acids. A large inferior tur.