Uterine disorders : their constitutional influence and treatment

Preface

There already exist so many comprehensive and trustworthy text-books about Diseases peculiar to Women, that the motives which have induced publication of this work need a few words of explanation.

When required, many years ago, to undertake the charge of a large number of women suffering from uterine disorders, I experienced considerable difficulty in endeavouring to reconcile, for practical use, the discrepant opinions as to the pathology and treatment of such cases. The last books afforded precise information as to the latest views ; but a certain disadvantage attended this very exactness, — for that scrupulous impartiality which records, with equal favour all opinions, however conflicting, which supplies knowledge and delegates the work of judgment, is rather admirable than practically useful.

As initiative to my personal study of the subject of Diseases of Women, I determined to work through its early history. This long and laborious task afforded certain curious and

Viii PREFACE.

significant results ; some of which are embodied in the introductory chapter. In the subsequent parts of this work I have endeavoured to turn to account the method which I early adopted for my own guidance. There is no disease without some foregone disorder ; and the importance of discriminating the causes of disorder in its various stages, led to a recognition of the comparative value of remedies— to adapting the plan of treatment to the exigencies of each case.

It is only after a somewhat exceptional experience, and the study of notes accumulated from thousands of cases, that I venture to speak somewhat authoritatively on certain points yet in dispute, and to suggest various new methods of treatment in uterine disorder and disease. Wherever this responsibility is assumed, it is marked by the use of the personal pronoun, signifying that I hold and defend the position thus adopted.

It is no part of the purpose of this work to discuss discrepancies of opinion. My endeavour has been to build up from sound materials a method of investigation which shall enable the varieties of uterine disorder and disease to be understood, distinguished, and treated according to the ordinary principles of pathology. Elaborate cultivation of one small plot in the field of medical science need not constitute the labourer a specialist, so long as his work is openly and honestly done. I contend that diseases of the womb obey the same laws,

PREFACE. ix

and are just as amenable to rational treatment, as diseases of other organs of the body, neither more nor less. Indeed, the peculiarities of the physiological life of the womb render this correlation even more remarkable, and throw still further into the shade those special doctrines concerning uterine pathology —

" Which had not been if reason ruled, Or wisdom wove the web."

H. G. W.

66, Harley Street,

Cavendish Square.

SYNOPSIS.

Chapter I. The Historical Disorder Of Uterine Pathology

Modern revival of uterine pathology; the English and French schools, pp. i — 5. The gynaecology of the Egyptians, of the Israelites, of the Greeks, of the Romans, 5 — 7. The Alexandrian school, Aetius, 7 — 12. The Arabian school, 12 — 14. The history of the speculum, 14 — 19. The early European schools, 20 — ai. Primerose, 21 — 23. The mischief of modern specialism, 23 — 2jJ.

Chapter II. Disorders Of Place

The order of place, pp. 27 — 28. The dynamic influences, 28 — 36. The vascular influences, 36 — 43. Uterine displacement, 43 — 48. Prolapsus, active, 49 ; passive, 52. Treatment, 53. Pessaries, ji, 56. Hydrochlorate of ammonia, 59. Cases, 60. Anteflexion of uterus, 63 — 67. Anteversion, 67 — 72. Retroversion, 73. Retroflexion, 74. Treatment, 74 — 79. Cases, 79 — 81. Supporting pessaries, 82 — 84. New intra-uterine spring pessary, 86. Lateral displacement of the uterus, 88 — 89. Displacement of ovary, 89 — 91. General treatment of displacements, 91 — 93. Rest. 93. The bath, 93. Injections, 94. Medicines, 95.

xii

SYNOPSIS.

Chapter III

The natural history of menstruation, pp. 79—112. Amenorrhcea, U2. Emmenagogues, 113. Systemic amenorrhoea, 114. Treatment, 116— 118. Ovarian amenorrhcea, 118— 121. Uterine amenorrhcea, 121. Use of ergot, 123—125. Suppression of menstruation, 12^5 of mental origin, 126; of physical origin, 127-13*- Joint-pains attending amenorrhcea, 133—136. Vicarious menstruation, 136—140. Menorrhagia, 140—144. Systemic menorrhagia, 144—146- Ovarian menorrhagia, 146—147. Uterine menorrhagia, 147— Treatment, i-Ji-x^ Dysmenorrhea, i57- System* dysmenorrhea, 159-166. Ovarian dysmenorrhea (neuralgic, capsular, and stromal), 167-173. Uterine dysmenorrhea (neurotic, structural, obstructive, and membranous), 173—188. Leucorrhea, 188-199- Coincident infra-mammary pain, 200. Treatment, 200-205. Sterility (systemic, ovarian, and uterine), 205 — 209.

Chapter IV. Disorders Of Structure

The order of structural change, pp. 210-214- The inflammation theory, aij-»x. Cacoplasia, 223-^24- Cancer, 224-229. Treatment, 229-232. Epithelioma, 232, 233- Rodent ulcer, 233,234. Tubercle, 234^35- Syphilis, 23^ 7- HetoroplaL, 237, >38- Hyperplasia, 238-240. Vascular growths 240-242. Uterine hypertrophy, 242-244- Fibrous tumours and polypus uteri, 244-^55- Aplasia, 25^. Granular erosion of JervbLi 256_258. Treatment, 258-261. Eruption, on cervix uteri, 26!-263- Syphilitic aplasia, 263. True ulceration of the cervix, 264, 265.

UTERINE DISORDERS.

Chapter I. The Historical Disorder Of Uterine Pathology

It is now nearly half a century since professional attention was sharply awakened to the inefficiency of the routine practice then generally pursued in Diseases of Women. It was only by a coincidence that the subject came under consideration both in England and France at nearly the same time. Such concurrent investigations (with sometimes even simultaneous but independent discoveries) are by no means rare in the history of science. Thereby is simply signified so general an advancement in knowledge, either general or special, that the same goal presents itself, and the same means are available to many eager observers ; all pressing onwards in the same direction.

The works of Sir Charles Clarke and of Dr. Gooch in this country, and of Recamier and Lisfranc in France, may be accepted as those which exercised the most important influence in directing modern attention to the necessity for a more exact study of Diseases of Women. The distinguishing characteristics of the two schools of uterine pathology were just as strongly

B marked then as they are now. In this country there was, and still is, a tendency to regard uterine affections as intimately associated with, and in the main originally dependent on, some general derangement-to look on the uterine disorder as « a fragment of a constitutional malady." According to the doctrines of the French school, it is the local ailment which is almost exclusively regarded, the constitutional symptoms being attributed to the wide-spread influence exercised by the demonstrated Serine disease. Of this latter view the most zealous exponents were to be found among those energetic practitioners who first introduced into the practice of this country the methods of local investigation and treatment pursued in the French schools. It cannot be doubted that the sudden and enthusiastic advocacy of a very general employment of The Speculum, prominently and persistently declared to be essential for successful treatment, was met by a somewhat injudicious and unreasonable antagonism ; the use of a valuable aid to diagnosis and treatment being confounded with its possible abuse by unskilful or unscrupulous persons. Something of this strong opposition might also have been due to the bold proposition so frequently advanced even to this day, that the world was in dense ignorance about utennc diseases until the speculum of Recamier threw light on the subject.

« it was not till of late years," says Sir J. Simpson,* ' that we had certain means and measures of knowing when inflammation or when uke^^^

i Obstetric Memoirs, p. 3.

been asked," writes Dr. Mitchell, " how it happened that our forefathers treated female diseases successfully, as well as the present generation of medical men, without the use of the speculum. To which I would reply, that many went to the grave with the seat of disease undiscovered."1 Dr. Tilt commences his elaborate work2 thus : " The dark ages of uterine pathology extend to 18 16, when by showing the possibility of an ocular examination of the womb, and urging the frequent necessity of doing so, Recamier enabled his disciples to apply to diseases of that organ the recognised sound principles of general pathology. Those who followed have necessarily derived precision by adding ocular demonstration to the previously known methods of studying diseases of women." So enthusiastic, indeed, were some of the advocates of the use of the instrument that they did not scruple to adopt very exaggerated views. " What opposition," writes Dr. Balbirnie, " did not Harvey's discovery of the circulation of the blood create ! He was an innovator. Jenner also was an innovator. The science of auscultation also was opposed in Great Britain ; but all these have long achieved their triumph. Doubtless a similar opposition awaits the speculum. We go forth its advocate ; we proclaim ourselves the apostle of the speculum ; with that instrument we link our fate, and by that we will stand or fall."3 Such statements may be fairly held to imply a strong belief that

1 Practical Remarks on the Use of the Speculum. 2 Uterine an5 Ovarian Inflammation.

Treatise on Organic Diseases of the Womb.

B 2

UTERINE DISORDERS.

something new had been accomplished, something special to the age, and signifying a great advance in knowledge on account of recent discovery. But the counter arguments employed were just as indiscreet, and the statements often as exaggerated. And this was the more remarkable, since the key-note of the only true and scientific method of investigating uterine diseases had in reality been struck in the admirable works of Clarke and Gooch. It might then have been fairly urged that, according to the method of research of the English school, all constitutional causes producing disorder should be investigated, all the teachings of physiology and general pathology held in mind, and all the extended knowledge of the influence of remedies, and of hygienic medicinal methods laid under contribution, in order to arrive at a correct diagnosis and to insure a good result from treatment. This would have formed the real innovation : for the use of the speculum, and of every one of the newly suggested means and measures of local investigation introduced by the French school, indicated only a revival of the practice pursued in ancient times ; when little was known of physiology or pathology, and still less of the rationale of treatment. Had this argument been strongly urged and upheld by the very substantial evidence which a little research might have supplied, it is probable that less prominence would have been given to that exclusive use of local means of investigation which chiefly led to uterine disorders first being considered as a speciality. The evil results which have followed are. twofold : « Some men regard the local ailment as everything, others almost lose sight of its existence, and it is difficult to say which is the most mischievous."1 The warm discussions which led men to range themselves into parties might possibly have given place to a method of research more consistent with true scientific advancement, had the curious history of uterine pathology, how it was anciently studied, and why it came to be disregarded, received its due share of attention.

The earliest records of medicine point to the Egyptians as studying the science, even in the most remote periods of their history. A recently translated papyrus2 contains a treatise on medicine transcribed about the nineteenth dynasty, but believed by learned Egyptologists to have been written in the time of the early Memphitic kings (2600—3500 B.C.), at least a thousand years before the birth of Moses. Now, a study of those parts of the law of Moses wherein special allusions are made to the hygienics of women, and precautions advised concerning them, indicates very clearly that the prudent regulations enjoined (so necessary under the conditions and climate in which the people lived) were founded on observation of the evils arising from neglect. Moses, we are told, was skilled in all the knowledge of the Egyptians ; and the rules and observances mentioned were such as would have struck any acute and inquiring stranger living in a land where medical precepts had gradually influenced the domestic habits of the people. That the Egyptians maintained a world-wide medical repute, even down to far later

1 Dr. West : Diseases of Women. 3 In the Berlin Collection.

UTERINE DISORDERS.

times, we have abundant testimony. Homer expressly mentions them as skilled above all men, and directly descended from Apollo.1 It is beyond doubt that the earliest Greek physicians derived much of their knowledge from Egypt ; and if the essays ascribed to Hippocrates— certainly written in his epoch— represent the direction of observation in his time, it is evident that there was then a very advanced knowledge of the Diseases of Women.

The works of Aretaeus and Galen strengthen this belief; for it is important to remember that dicta as to diagnosis and treatment of these disorders indicate very long and careful observation, in order to distinguish accidental conditions compatible with health from those symptomatic of disease. In the works attributed to Galen occurs the earliest allusion to the speculum vagina? as a distinct instrument from the speculum ani ; whilst Aretseus describes ulceration of the womb with a precision which leaves little doubt that he also employed the instrument for diagnosis. These authors both studied at Alexandria and practised at Rome. What Athens had been in philosophy and Corinth in arts, Alexandria continued, for several centuries, to be as a centre of medical lore ; and even to have studied there was accepted as a qualification to practise. But there gradually arose at Rome an independent school. Celsus, its most distinguished writer, was an exception to the general rule ; as he had

Odyssey, book iv. 1. 931.

neither studied at, nor did he love, the Greek schools. Unfortunately, his most important chapter on uterine maladies is, in great part, lost , but we may judge from a passage in his works that, even in his time, diseases of the genital organs were so far a speciality of the Greek school that he could make it a subject of covert sarcasm. In treating of them he says : « Their nomenclature among the Greeks is not only tolerable, but now fully sanctioned by practice, for they are freely employed in almost every volume, work, or treatise of the physicians ; but with us Romans these terms are filthy, and never employed by any one who has a proper regard for modesty in language; therefore it is evident that there is no small difficulty in maintaining at the same time a delicacy of expression whilst delivering the precepts of the art." Whether it was jealousy, or a continuance of that same bitter feeling towards the Grecian schools of medicine previously exemplified by Cato1 and Pliny,2 it is evident that some other than the alleged motive prompted Celsus to write this sentence ; for, being a shrewd practitioner, he must have known that the morality of the Romans— as de scribed in the sixth satire of Juvenal— scarcely required such tender solicitude. Soon after the death of Galen the great medical school of Alexandria was broken up. Its fame had gradually waned, but the well-stored library still remained, enriched by the addition of the manuscripts from Pergamos, another medical school. So vast were the literary treasures that it is reputed 700,000 volumes were destroyed when the

a Lib. xxiv. cap. viii.

UTERINE DISORDERS.

library was burnt by Omar a.d. 642. How many of these works treated on medicine we can only conjecture. Yet we have good grounds for a surmise that there was collected in that grand library all that the gathered experience of generations had left for preservation. Alexandria had been for centuries the centre of medical teaching ; and here must have lived and worked those masters of the art to whom the pupils came for instruction. It was their Alma Mater ; where else could the manuscripts be so fittingly preserved ? And here, about a hundred and fifty years before the final destruction, an industrious compiler laboured, his lifetime through, to condense into practical form the literature of medicine of the period, working among the stores of the great library. His Magnum Opus is still extant, and is, without doubt, the most valuable existing work on ancient medicine, though but little known.

Aetius lived at Alexandria ; and probably practised there, as he makes mention of cases under his own care. But the chief labour of his life must have been the compilation of his book. It was an endeavour, and probably a successful one, to represent the practice then taught and followed in whatever concerns the diagnosis and treatment of disease j omitting, as far as possible, the discussion of theories and allusions to prevalent squabbles about systems. He refers to and gathers from many authorities, but most conscientiously acknowledges all the sources whence his information is drawn ; and he condenses with admirable clearness. His work embraces the whole range of medical science as then known. I purpose only alluding to that section in which he treats of Diseases of Women. In addition to its special historical interest, there are some grounds for believing it to be the only authentic and complete treatise on the subject now extant out of all those which were written previous to the time when Aetius lived ; for Hieronymus Mercurialis attributes the treatises of Hippocrates on the nature and diseases of women to one of his disciples 1 — a view supported by Schultze and others. The chapter in Celsus is imperfect, as also is the history of treatment in Aretaeus.6 The book " de Gynaeciis," in Galen, has been held to be fictitious by most editors. Of the works of Soranus, Oribasius, and Rufus, only fragments remain ; whilst other authors to whom Aetius refers have their names on the roll of the history of medicine, but their works are entirely lost. Such are Philumenes, Archigenes, Pelagrinus, and Asclepiades. This last (from whom Aetius takes his chapter on healing of ulcers of the womb) is the only one to whom we find any collateral reference, since Cicero speaks of him as his physician and his friend. Lost also is any notice of that first Moschion to whom Pliny attributes a tract " de Pessariis," and of Antyllus, from whom Paul of iEgina derived a chapter on the same subject.

In the sixteenth book of his work Aetius treats principally of Disorders of Women, devoting to the subject a hundred and twelve chapters, varying in length from a few lines to several such pages as these. Thirty-seven of these chapters treat of pregnancy, of parturition, and of suckling. There

Lib. iv. cap. xx.

2 Lib. ii. cap. xi.

lO

UTERINE DISORDERS.

are six chapters on various kinds of ulceration of the womb, three on abscesses, two on displacements, two on obstructed and imperforate uterus, seven on growths occurring in the vagina or uterus, and eighteen chapters on menstruation and its disorders. He has special chapters for hysteria, fibrous tumours, pelvic abscess, haematoma, displacements, &c, and devotes one very long chapter to inflammation of different parts of the uterus and its. treatment. Only a series of extracts could convey a just estimate of the extent of special knowledge indicated in these descriptions. But so far as concerns the use of the speculum, it is especially worthy of note that he refers again and again to its employment, as a matter of course, in the diagnosis or treatment of ulceration, of tubercula (polypi) in the neck of the uterus, of sessile growths in the same situation, and of calculi and haemorrhoids of the womb ; of imperforate uterus, and abscess of the womb. Digital examination is also mentioned as an ordinary means of investigation, " particularly when there is pain denoting ulceration, which is especially liable to happen on the cervix uteri." The treatment he describes includes most of our modern appliances ; in addition to a special description of the use of the speculum. First and most constantly recommended are medicated pessaries, for which he gives upwards of a hundred formulae.1 They included not only the rags smeared with ointment, to which pre-

i " Dr. Simpson first introduced medicated pessaries into use several years ago!" Ed. Med. Journal, June, 1848, p. 886.

HISTORICAL DISORDER OF UTERINE PATHOLOGY. II vious writers had referred, but also certain preparations compounded and used exactly as they are now-a-days prescribed. The ingredient which forms the basis must be of such kind that it melts at the temperature of the body ; it must be so firm that, when cold, it can be neatly introduced ; and the relation of these component parts must be varied according to the nature of the conveyed medicaments. In modern practice wax and lard formed, until very recently, the vehicles. The ancient writers used other ingredients, such as beef and deer marrow, goose fat, &c. ; and Aetius describes how, in making suppositories of this kind, the ingredients are to be melted and mingled and allowed to cool before being used.

The use of sponge tents is also very accurately described by Aetius ; how they must be well dried and smeared with unguent, and introduced (with a thread attached) successively until full dilatation is accomplished. In cases where the canal of the cervix has been imperforate, a tin tube is to be inserted in order to maintain the passage, and a speculum subsequently employed, any exuberant granulations being touched with verdigris.1 The importance of injections, the use of hip-bath, both plain and medicated, the employment of the douche, and application of fumes and vapours by means of a reed introduced into the vagina and connected with a vessel containing the medicated fluid, are all mentioned as ordinarily employed in

1 The employment of a porte caustique had been previously mentioned by Oribasius. Describing the application of caustics, he adds : Uteri autem vesicaeque exulcerationes iisdem remediis curantur sed opus est instrumentis quibus intromittantur."

I 2

UTERINE DISORDERS.

practice. We may fairly infer this ; for Aetius, throughout his work, so carefully refers any special method of practice to the originator, that whenever his description of treatment has no such acknowledgment we may conclude his description to apply to the treatment ordinarily pursued by the most able practitioners of the day.1

In his description of the various displacements of the uterus, Aetius specially mentions the value of rectal examination in retroversion, and how it may aid re-position ; and he states, among other suggestions as to treatment, that the correction of lateroversion of the uterus may be effected specillo et digito. Here he probably only referred to an ordinary long probe ; the recognition of an instrument, specially used as the uterine sound is employed, was of later date.3

Before tracing further the history of the speculum, I may allude to a matter naturally suggested when considering what the practice was when Aetius lived, how thoroughly it fell into desuetude, and has only been revived in comparatively recent times. There was the experience of many centuries, there was the testimony of acknowledged authorities, and there were always suffering women urgently needing help in old times, as at the present time. And if there was any faith in what Aetius wrote, and in those whom he quotes, why were

1 In the most recent bibliography of writers on uterine diseases (Scanzoni), the work of Aetius is not mentioned.

2 Wierus (1657) gives the first accurate description of an instrument exclusively used for uterine exploration.

their teachings disregarded for upwards of a thousand years ? It forms a somewhat curious and significant episode in professional history. After the dispersion of the Alexandrian school, the professors of medicine, though scattered, were still received with honour by their Moslem conquerors. What they could teach was eagerly gathered, except when their instruction clashed with any tenet of the Mahommedan creed. The Arabian school, which then arose, comprised equally industrious workers and equally accurate observers. But the study of Diseases of Women was not cultivated among them ; for there was an insuperable bar to the attainment of practical experience on the subject. It was against the Mahommedan creed that women, . even in their suffering, should undergo personal examination except by one of their own sex. Their degraded social condition prevented their attaining any such position as that to which the women of Greece had vindicated their claims. Even an Hypatia or Agnodice could not have withstood the blighting influence of Moslem sensuality. In the Arabian writings there is only very general mention of Diseases of Women, the matter being principally copied from the Greek books ; whilst the local treatment was left in the hands of the midwives. The works of Avicenna, Serapion, and Haly Abbas show how far the Arabian physicians permitted the subject to drop out of notice. It is true that Albucasis, one of the latest writers of the school, refers to these diseases at greater length, but he appears from his writings to have been a Jew. It is he who first mentions herpes of the uterus, and the use of an air pessary for the vagina.1 Then, as to this day in the East, the midwives undertook the work. One of them, Trotula (thirteenth century), published a treatise on uterine disorders, in which she expressly mentions that many Saracenic women practised at Salerno.

Reverting to the speculum, it is doubtful if the history of any single instrument has been so' well preserved. We find it figured in Scultetus, and his description is as follows (the engraving is accurately copied on opposite page): "Fig. a is an instrument which they call ' speculum ani et vaginae uteri,' in that by its help ulcers of the rectum and of the vagina and uterus may be seen, to be carefully observed according to their extent and kind. The part of the speculum, a, drawn open and called male, is applied for men ; but the closed part, B, is applied to women, whence it is called female." This is a modification for general purposes, but « Fig. 4 is the large speculum matricis, and is only used for women, when a dead fcetus has to be cut away or an ulceration of the womb to be inspected." To illustrate the method of using this speculum, he gives a representation of a woman with the instrument introduced and dilated ; he describes it as that which Paulus ^Egineta mentions, whose words he correctly quotes as follows : « The person using the speculum should measure with a

probe the depth of the woman's vagina, lest the tube of the speculum being too long it should happen that the uterus be pressed upon The tube is to be introduced having the screw at the upper part, and the speculum is to be held by the operator, but the screw turned by the assistant ; so that i6

UTERINE DISORDERS.

the laminae of the tube being separated, the vagina may be dilated."1

Now Paul of iEgina lived upwards of a century after the time of Aetius ; and this very description is an almost verbatim copy from that author, but without the conscientious acknowledgment which I have mentioned as characterizing the book of Aetius, whose description runs thus :

The same description, with very slight difference, is to be found in Albucasis (fourteenth century). And it may be conjectured that Scultetus was acquainted with the instrument, but not with its correct use, since in the plate he represents it as introduced with the handle downwards.8 It is because of this historical reference that I first mention the illustrations of John Schultz (or Scultetus, as he styled himself in the fashion of those days). He was a pupil of Hieronymus Fabricius (1620), who also delineates a three-bladed speculum, whilst others still more complicated are represented by Galbelchouer i Lib. vi. cap. lxxiii. 2 Lib. xvi. cap. lxxxvi.

3 Armamenta Chirurgica, 165°, engraved from the folio edition. The plates in the smaller copies are very inferior, and frequently altered. The engraving in the original comprises several other uterine instruments, but I have only here represented that marked Fig. 5, on account of its identity in principle with the modern hysterotome.

(1637) and Ambrose Pare (1640). There can be no doubt or the purpose of the speculum as depicted by them ; but a still earlier writer, Jacobus Rueffus1 (1587), has a drawing of a somewhat similar instrument, which he calls the speculum matricis, and describes as employed for dilating the os uteri in difficult parturition, " expedienda instrumenta et pneces piae ad Deum fundendae." He figures also an apertorium for the same purpose, and the first smooth-bladed obstetric forceps.

From the time of the revival ot medicine we find allusions to the use of the speculum becoming more distinct and frequent. In some works it is figured, in many its use for investigating uterine diseases is mentioned as a matter of course. Usually the three-bladed speculum was employed. Wierus (1657) somewhat modified it by making the blades flat; and its frequent use may be inferred from the general description which Garengeot appends to his elaborate representation of it : " L'usage de speculum matricis est de dilater le vagin pour y apercevoir quelques maladies et pour y operer,"2 A still more complicated instrument is figured by Arnaud in his " Memoires de Chirurgie" (London, 1798). With this the vagina was dilated by six wires, opening to a considerable extent by a most ingenious mechanical adaptation. Thus there is a tolerably

1 His work, " De Conceptu et Generatione," has a quaint allegorical woodcut representing the Temptation. The tree of knowledge of good and evil has a human skeleton for its stem and trunk, the arms spreading out into fruit-bearing branches with the serpent coiled among them.

C i 8

UTERINE DISORDERS.

continuous history of the speculum from the time of Aetius down to the present day.

But in the year 1818 there were disinterred at Pompeii