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no reason why we should not use it. Another point I wish to make
in regard to the use of pituitrin is this : I have found that there is not
much danger in using it, even w^hen dilatation is slight, late in labor.
For instance, if the woman has been in labor some twelve or eighteen
hours or longer, and yet there is insufficient dilatation, then I have found
its use effective and harmless. I have given it in primiparas as well as
multiparas in what was considered insufficient dilatation, but in both
instances it was late in labor, and in neither instance Avas there any bad
effect whatever.

Dr. Cyrus Thompson, Jacksonville : I desire to commend the general
wholesomeness of Dr. Pugh's paper and to emphasize the fact that prac-
titioners generally do more damage than good by the use of pituitrin.
If it is used at all, it ought to be used in very small doses. If you give
the ordinary dosage in ordinary cases, even as much as Dr. Pugh has



212 NOKTH CAROLINA MEDICAL SOCIETY,

stated, it is altogether possible that you may do a considerable deal of
damage. Dr. Dickinson has said that he used it for a year and got no
effect from his dosage whatever. He explains that by reason of the pos-
sible deterioration of his product. I used an ounce of pituitrin over a
period of from twelve to eighteen months, and the last of my specimen
was just as effective as the first. I don't know anything at all in the
nature of a drug that is more dependable for effect than pituitrin. You
always, if your labor is at all in progress, get definite results from the
dose.

Now, in a general way, I want to say this, that as to the use of pitui-
trin and as to the use of forceps, the practitioner in general is too much
inclined, and therefore inconsiderate of the woman, to rush to the use of
something that saves him time. I think, and I think that it ought to be
emphasized and impressed upon the profession everywhere, that every
labor ought to be left to come along normally, if it can be completed so,
without the use of pituitrin, forceps, or anything else, and no labor ought
ever to be hurried up for the saving of the attendant's time. When you
attempt to save time, it saves it for you at the expense of the woman who
has been put into your care. I never give more than from three to five
minims. I have given a little more than that sometimes, and have said
to myself, "Behold, how great a matter a little fire kindleth !"



GYNECOLOGY.

]^E1jEASTHEI^IA IX RELATION TO GYNECOLOGY.



Rosalie Slaughter Morton, M.D., New York City.

(Fellow of the Xew York Academy of Medicine; Clinical Assistant and Lecturer on
Surgery, New York Polyclinic Medical School and Hospital.)



Mi: Chairman, Members, -and Guests of the Section:

May I take this opportunity to express to you my pleasure in attending
tliis meeting of the Medical Society of the State of JSTorth Carolina, and
to tell you hoAv greatly I have been interested in the papers which have
been read ?

When three years ago I was first asked to lecture to the post-graduate
students at the Xew York Polyclinic Medical School and Hospital, I
thought I should be taking ''coals to Newcastle" in doing so, for there
are no fihysicians and surgeons in the United States better posted or
more capable of good work than those who come to refresh their minds
and keep in contact Avith the latest work being done in that city. The
majority of men and women physicians who come to the Polyclinic Hos-
pital are from the Southern States. Having been born in Virginia, I
know well the work of many doctors there, and, realizing that they are
typical of the practitioners throughout the South, I am convinced that
those of us Avho live in the great medical and surgical centers could learn
more from you than you can from us. The unselfishness and willingness
with which you go, in all kinds of weather,* on all sorts of roads, at all
hours of the day and night, to all classes of patients, often finding on
your arrival nothing of which you can make use, and no trained assist-
ance, taxes the mental and physical capabilities to a degree which we do
not fail to appreciate, although we have lost our resourcefulness through
becoming used to having everything Avell prepared for us in large hos-
pitals, and trained nurses to go before and put things in readiness for u^
in the homes of patients, as well as colleagues upon whom we can always
call to help us meet any emergency.

In contrast to this, I have known a Southern physician, covered with
beads of perspiration, suffering acutely with malaria, to go in a cold rain
10 miles in the country to see a patient, not half so sick as he, and on
arrival, finding the family poor, leaving a supply of medicines and
refusing to accept a fee. And also a surgeon called at 2 o'clock in the
morning to a patient he had never seen before, by a messenger who could



214 NORTH CAROLINA MEDICAL SOCIETY.

gh-e no further history of the case than that the patient was suffering
with cramps. Hastily preparing to meet whatever emergency he might
find, the surgeon drove up in the mountains and found a man at the
point of death Avith a perforated appendix. 'No basins or other con-
veniences for work, outside of those he had taken with him, were to he
had. It was necessary for him to etherize the patient and operate at the
same time, every moment watching pulse and respiration, and turning
quietly from the surgery, as soon as the patient showed signs of coming
from under the anesthetic, to etherize him, and as soon as he was relaxed,
turning again to his abdominal work ; the family in the meanwhile sur-
rounding him in a state of panic, he calmly, deftly, and courageously
met the situation in a manner which showed it was no unusual occurrence
for him to meet and conquer death, by the combined force of ability and
those elements of character which make the truly great. Colleagues of
the South, Avhat is there to teach such physicians? And yet these inci-
dents are so usual, no doubt mentioning them brings similar experiences
to the minds of each man and woman present.

My hope in coming to you has been that I might be able to present a
helpful point of view regarding "JSTeurasthenia in Eelation to Gynecol-
ogy." I have, therefore, decided in the limited time at my disposal, not
to dwell upon the nerve fatigue resulting from the more obvious patho-
logical gynecological conditions caused by trauma, inflammation, and
growths of various kinds, but to take up a few points not so frequently
accentuated, and upon which I should greatly value your discussion,
namely, fatigue, congestion, and auto-intoxication.

Primarily, it is of interest to consider whether the question of neuras-
thenia in women, as compared with men, is not somewhat overestimated.

Six years ago I had the honor of organizing for the American Medical
Association, as the first chairman of their committee on Public Health
Education, courses of lectures, to be given to the public throughout the
United States through the county medical societies, on the causes of pre-
ventable diseases ; and in the series of eight to twelve lectures which have
been given for the last six years, under the local division of this National
work by the Public Health Education Committee of the Medical Society
of the County of New York, there has always been a lecture dealing,
from one point or another, with "The Causes and Prevention of Nervous
Exhaustion." We have observed that although this lecture was given
at 3 :30 in the afternoon, when most men are engaged in business,
invariably a larger proportion of the audience have been men than at
any other of the series of lectures, and that many of them have stood
throughout the one and one-half to two hours given to the discussion of



GYNECOLOGY. 215

neurasthenia, Avhieli suggests tliat tliey took a very personal interest in
the subject. On one occasion, when presiding, I laughingly said that
every one in New York had had, or expected to have, nervous prostra-
tion, due to the stress and strain of life in that metropolis ; but on receiv-
ing the reports of similar lectures from all over the United States, I
learned that this subject was always one that interested a large audience ;
that many men were invariably present, and asked questions from the
floor following the lectures.

Several years ago, at one of the scientific meetings of the N'cav York
Academy of Medicine, a paper entitled "The Neurasthenic Woman" was
presented, and 60 per cent of the cases quoted in the paper were men,
showing that the author had chosen Avhat he thought a popular title,
rather than one accurately describing his paper. This led me to consider
the causes which, in both men and women, produce neurasthenia; and
then to focus upon their special relation to gynecology.

When we carefully consider nerve fatigue, we realize that it is as com-
mon to men as to women. In the average family the men are obliged to
use as much energy in doing $15 worth of work to earn $5 as the women
of the family use in making $5 do the work of $15, and from the begin-
ning of history to today, in studying the activities of men and women,
we find that through the various evolutionary epochs women have had
as much responsibility, though of a different kind, and as many causes
for nerve fatigue as men. Therefore, if the number of cases in womeii
do not greatly outnumber the cases of neurasthenia in men, we may
assume that fewer are of gynecological origin than is customarily sup-
posed. In order to verify this, in preparing a paper on '"'"The Effects of
Industrial Strain on the Working Woman," I made a study of the em-
ployees of six of the large department stores in 'New York City, in which
women are employed, to ascertain the use made by them of the rest-room,
or emergency hospital, situated in the store. I found that the average
temporary illnesses showed that the number of employees who sought
relief was divided between men and women in about equal ratio to those
employed. Of the women patients, approximately one-third suffered
from headache, one-third from indigestion and miscellaneous ailments,
and only one-third had menstrual disorders, which makes a very small
proportion out of the total number of employees. For instance, in a
store which employed 3,000 women, there would average not more than
ten a day who went to the rest-room for a few hours on account of dys-
menorrhea. In one of the stores which employed approximately 3,500



*neaa before the Section on Hygiene of Occuinition of the International Congress of
Hygiene and Demograpliy. Washington. D. (".. Sei)leml)er LM;, lill:^. published in the
American Journal of Obstctrioi and DiKca.fr.s iif Women (iiid Cliildroi, Vol. LXVII, No. 1,
1913.



216 NORTH CAROLINA MEDICAL SOCIETY.

women, the nurse who had been in attendance for eight years said that
she knew of only fifteen cases of permanent pelvic trouble brought on
by work in the store.

In one store, which is situated at the junction of several surface and
elevated street car lines, the daily attendance in the store hospital was
double that of a store in a more quiet location. The ventilation of the
former store is also poorer than in the latter. The proportion of those
who suifered from dysmenorrhea was larger in the store which was not
so well ventilated and which was noisier, showing that fatigue had a dis-
tinct effect upon health during menstruation.

A study of the 3,800 employees in the head office of the Metropolitan
Life Insurance Company showed that absences for sickness, which had
been greater among the women than the men, were reduced to an equal
ratio after the Metropolitan began furnishing a wholesome lunch for its
employees, as the average amount paid by young women for luncheon
was 15 cents as against 30 cents paid by the average man doing the same
work. The fatigue resulting from lessened nutrition had such an appre-
ciable effect upon the work that the life insurance company has found
their ]3rovision of luncheons a wise economic step.

In many cases adjustment of the mental, emotional, and physical strain
under which a woman lives removes gynecological disturbances which
were supposed to be of pelvic origin, but which were really secondary to
malassimilation, poor nutrition, anemia, insomnia, etc., induced by
fatigue.

Congestion associated with, or independent of, misplacement is of
anatomical interest, for the uterus has normally ample room for its pre-
menstrual increase of size and weight, and the increased circulation in
the pelvis at that time, by adding tone to its supporting ligaments, coun-
terbalances the ptosis-producing effect of gravity. The increase of circu-
lation is exemplified in the usual free movement of the bowels, just before
menstruation begins, in persons ordinarily constipated. Any misplace-
ment interferes to some extent with circulation, and congestion results,
which may or may not produce *pain, according to the manner in which
the rectum accommodates itself to the permanently retroverted uterus ;
for, if it passes to one side of the uterus, instead of back of it, unless the
patient is constipated, there is no pressure on the sacral plexus, and the
patient does not have backache. This difference is clearly demonstrated
when, if there are no adhesions, the uterus is lifted well f orAvard and kept
in normal position by a pledget for twenty-four hours ; the first bowel
movement causes the rectum to resume its proper position posterior to

*See paper on "Dysmenorrhea" read before the Medical Society of the State of New
Yorli, Section on Gynecology and Obstetrics, April 30, 1914. Published in New York
State Journal of Medicine, January, 1915.



GYNECOLOGY. 217

the uterus; when the pledget is removed, and the uterus drops back, it
presses the rectum and contents against the sacral nerves, and at once the
patient has a sensation of weight and pain not experienced before.

The dull feeling of being below par, without definite symptoms, comes
more often from pelvic congestion and slight pressure than from any
other cause. The relief which folloAvs permanently restoring the uterus
to its normal position is marked. Of the many operations in use for this
purpose, I have found a modified form of Gilliam most satisfactory, i. e.,
drawing the excess length of the round ligaments through the internal
ring, and fastening them to the abdominal muscles, by stitches, which do
not interfere with the circulation in the ligaments ; especially valuable in
this connection is a suture which suspends and does not constrict the end
of the loup.

A case in which this was done was that of Mrs. C. G., 34 years old, who
had been for seventeen years, off and on, in sanitariums in Europe and
the United States. When her family went abroad to travel they took her
across the ocean, and, as she was not strong enough to tour, left her in a
Swiss, German, or other sanitarium, in a convenient place to pick her up
again, Avhile they had weeks or months of interesting travel. This natu-
rally dei^ressed her, and on one occasion, because of her apathy, a bucket
of water Avas thrown on her, as she made no response. The next day the
nurse was instructed to start a series of petty persecutions to arouse her.
She, however, endured them silently, and Avas given up as an incurable
neurasthenic. In another sanitarium her food was put at the foot of her
bed and she was told if she was hungry she would get it. She said the
effort seemed to her more than the food was Avorth, as it made her back
ache to sit up and reach over, so she let it alone. Under this and similar
treatment she continued to become more nervously unstable, and one day
attempting to run aAvay, Avas classed as mildly insane and put under con-
stant obserA^ation. Finally she despaired of ever feeling Avell and, giA'iiig
up the struggle, settled into invalidism. Some years later, on account of
insomnia and headache, she came to see me ; as she seemed exhausted out
of proportion to the symptoms of which she complained, and said she
ahvays felt weak and faint AA^hen standing, and that automobiling tired
her excessively, I told her I thought a complete physical examination
necessary to make a diagnosis. She said, "Do you mean my whole body?
I haA^e neA'Cr been examined except for my nerves." I found family his-
tory negative; the appearance of her face, eyes, skin, teeth, and nails
normal. Throat and nose normal, ^o enlarged glands in neck. Tem-
perature 98.8. Lungs normal. Heart, anemic murmur accompanied
second sound; pulse 80, Aveak and regular. Blood pressure 90 in both



218 NORTH CAROLINA MEDICAL SOCIETY.

arms ; haemoglobin 60. Spine normal. Nerve reflexes of pupils, elbows^
knees and heels normal. Abdominal contents normal, except pain on
deep pressure over appendix. Pelvis : left ovary prolapsed, a little en-
larged, and sensitive; uterus retroverted; rectum to side of uterus; no
constipation. She felt strained when uterus was lifted ; complained of
pressure when it returned to retro-position. Chemical and microscopical
analysis of 24-hour specimen of urine normal. Height 5 feet 3 inches ;
weight 98 pounds. I operated on her at the l^ew York Polyclinic Hos-
pital January 18, 1915. Keplaced uterus by method described above;
punctured cysts of left ovary; removed chronically inflamed appendix.
She left hospital February 9tli, and gradually gained strength. Advised
her not to force herself at all, but to realize that although the cause of
her neurasthenia was removed, it would take several months for her to
recover nerve, and general tissue, tone.

In order to give her an entirely constructive viewpoint, I explained to
her the experiments of *Dr. George W. Crile and showed her micro-
scopic appearance of an area of the cerebellum of the normal fox, as
compared with the cerebellum of fox chased by hounds; area from
normal cerebellum of electric fish, compared with area from cerebellum
of electric fish exhausted by discharge of electric shock ; section of
normal cerebellum of rabbit, compared with section of cerebellum of rab-
bit after 109 hours of insomnia, the normal in each instance showing
plump cells with clear outline, firm nucleus and nucleolus, staining
easily. Those Avhich shoAved effect of fear, fatigue, and insomnia were
flat, vague in outline, with disintegrating nucleus and nucleolus, and
were pale. I explained to her the value of rest, sleep, food, oxygen, and
happiness to restore fatigued nerve cells to their normal condition, the
last being best secured to human beings by an impersonal mental and
physical occupation.

It seemed to me of psychological importance that she should realize
there was nothing peculiar about her case, and I thought the time was
well spent in which I made her condition clear to her, as her cooperation
was necessary ; in order that she should not become discouraged by the
days in which one tires easily and which are a normal part of every con-
valescence. Cheerfulness and hopefulness are insured by education of
the patient. She went to California on March 2d and in May I received
a joyous letter from her, saying that she was gaining weight and felt bet-
ter than she had ever hoped to. June 1st she wrote : "I used to say that
I so longed for just perhaps two days of perfect health, and now I have
it galore."



*See Kinetic Theory of Shock, The Lancet, July 5, 1013 ; and Anoci Association. W. B..
Sanders Co., 1915.



GYNECOLOGY. 219

There is something pathetic in this example of over-specialization, for
the relation of gynecology to neurasthenia had never been considered by
the many eminent specialists who had failed to diagnose her condition.
The years from 17 to 34 are sad years to spend in sanitariums, with a
naturally bright mind clouded by apprehension and depression.

On the other hand, if one may judge by the views expressed in several
eminent text-books, many gynecologists think the majority of Avomeu are
neurasthenic, and that this may invariably be attributed to some gyneco-
logical derangement. This opinion must result from the fact that these
physicians are so busy caring for the health of those who are ill they
have no time, opportunity, or occasion to see or consider the ovei'bal-
ancing number of Avomen who are perfectly strong ; and these physicians'
minds being focused upon their specialty, they seldom consider the prob-
ability of the neurasthenia being due to a defect in one of the *speeial
senses, faulty posture, cerebral or other congestion, lack of balance in the
internal secretions, nephritis, or other organic cause, blood dyscrasia,
malaria, or other systemic abnormality.

It does not seem to me fair to make the general assumption that a
woman is irritable and capricious because she is a woman; that her
potential motherhood makes her unstable, or that a diagnosis of neuras-
thenia should be superficially made. Yet this is done so frequently that
thousands of cases are so n'amed year after year by physicians who make
no effort to make an accurate diagnosis by means of a thorough physical
examination.

The tradition of the frailty of women may be due to the fact that
women generally wore tight stays in our grandmothers' time, and many
led a sedentary life, both of which favor pelvic congestion. A short time
ago, at the Colony Club in jN^ew York, a loan exhibit of the dresses worn
by ladies from one hundred to fifty years ago showed that the customary
fig-ure was slightly drooped, with rounded shoulders, a pinched waist,
prominent abdomen and overskirts which hampered free walking, which
was also interfered with by the footgear of the period. How strikingly
different are the costumes worn by the more athletic women of today,
who ride, fish, hunt, go camping, mountain climbing, swimming, rowing,
and winning championships in golf and tennis ! Although it may seem
remote, an erect bearing and free swinging walk do much to reduce neu-
rasthenia, not only by reducing pelvic congestion, but by preventing the
lowering of the costal attachment of the abdominal muscles ; for as soon
as the shoulders are bent there is an immediate sagging of the abdominal

вЩ¶"Constitutional States in Relation to Gynecological Conditions." read before the New
York Academy of Medicine, Section on (iynecology and Ol^stetrics, May L'6, 1914. I'ub-
Ushed in Xcic York Medical Journal, August, 1914.



220 NORTH CAROLINA MEDICAL SOCIETY.

walls, which permits ptosis of the stomach and intestines, and which,
through producing angulations and misplacements of the colon, rapidly
leads to cmto-intoxication.

A case under my care last year, Mrs. C. D. of Vermont, 50 years old,
suffering from pelvic congestion and severe brachial neuritis, gave a
history of two previous attacks of neuritis, one in right arm, one in left
arm, and of having been under the care of a distinguished gynecologist,
on and off, for years. She was treated by him for an inflammation
around the external os which was associated with small serum-filled flat
cysts which varied in number and which, on being opened, together with
vaginal treatments, relieved the congestion of the uterus for several
months. When she began feeling pelvic discomfort she would return,
complaining of "heaviness," and have more "blisters" opened. These
were accompanied by an irritating and profuse leucorrhea which would
last for several weeks and disappear, together with the blisters, under
treatment, only to reappear in a few months. Although she saw no
relation nor immediate importance in the fact, I learned that she had
"a poor appetite and a weak stomach," that her father had been subject
to "nervous dyspepsia, associated with acute attacks of neuralgia and
melancholia, lasting for several months every year." From her 18th to
20th years she had attacks of "inflammation of the bowels," recurring at
intervals from one to six months. Her abdomen was distended, pain was
on the right side in the region of appendix. She had morphine and rest
in bed for two weeks; attacks gradually diminished, although she was
not able to attend school for two years.

From the time she was 29 to 39 years of age she had recurrent "intes-
tinal attacks," one or more yearly. When 29 years old, for the last nine
weeks before her first child was born, she fainted so frequently she was
obliged to stay in bed continuously for six weeks. The last three weeks
she was able to be up part of the time. After delivery her bowels did not
move for ten days.

She had neuritis in left arm in .1905 and went to a sanitarium for
three months. In 1911, neuritis in right arm. Third attack, the one
which brought her to ]^ew York, began in right arm in October, 1913,



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