A practical treatise on inflammation of the uterus and its appendages, and on ulceration and induration of the neck of the uterus

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A

PRACTICAL TREATISE

Preface

The present treatise has been for some time out of print, owing to the favourable reception which it received from the profession. The delay in the publication of the second edition originated in my wish to give a complete history of inflammation in all the organs and tissues which constitute the uterine system, as elucidated by the application of physical investigation to the study of uterine diseases.

This I have at length accomplished ; and although nominally a second edition, the present is in reality a new work. It will be found to contain, not only a faithful history of the various pathological changes produced by inflammation in the uterus and its annexed organs in the different phases of female life, but also an accurate analysis of the influence exercised by inflammation in the production of the various morbid conditions of the uterine system, hitherto described and treated as functional.

Guided by the clinical observation of the last twelve years, — during which period I have constantly studied uterine disease in wide fields, and with the advantage of more accurate means of investigation than those generally employed, — I have endeavoured to demonstrate the important fact, that inflammation is the keystone to uterine pathology, and that unless the phenomena which it occasions be recognised and taken into consideration, all is doubt, obscurity, and deception.

The results at which I have arrived, and which are embodied in the following pages, are so diametrically opposed to the opinions current in the profession, as reproduced by the most recent and the most classical writers on uterine pathology, that they must appear startling, even to practitioners acquainted with the researches of Continental inquiry in this important branch of medical science. So thoroughly subversive f indeed, are they of all existing views respecting uterine disease, that nothing but the facility with which they can be tested could inspire me

4 PREFACE.

with the hope that they will, ere long, be universally acknowledged and adopted.

The diseases in question are amongst those to which females are most commonly exposed ; and proofs of this fact may be found by any practitioner in the daily routine of his professional duties. To test the value of my assertions he has merely to examine his patients. It must, at the same time, be borne in mind, that no one who does not set aside for the moment all previously formed pathological opinions, and impartially examine the cases in which the symptoms I have described are present, is competent to offer even an opinion on the subject.

Since the first publication of my researches in uterine pathology, above four years ago, a marked change has taken place in the opinions of a large portion of the profession — a change which may fairly be attributed, in a great measure, to the influence exercised by my writings. Several of the most eminent uterine pathologists of the present day — amongst whom I may name Dr. Montgomery* and Dr. Evory Kennedy!— have since then openly advocated views similar to those which I entertain respecting the frequency of inflammatory affections of the neck of the uterus. Moreover, I am able to state, from positive knowledge, that the practice of nearly all the eminent consulting practitioners in this department of pathology has been greatly modified within that period, and it is but rational to infer that their theoretical opinions have undergone a similar change.

In the present work there is much that is original, and new to the profession, both abroad and at home. I would more especially direct attention to the history : — of chronic metritis, and of the displacements which it occasions, of late years so erroneously viewed — of internal metritis, hitherto confounded with disease of the cervical cavity — of inflammation and abscess of the lateral ligaments in the non-puerperal state, never, as yet, described by any author — of inflammation and ulceration in the cavity of the cervix — of inflammation and ulceration in the virgin, — in the pregnant and puerperal condition, — in the aged, — and in connexion with polypus and with uterine tumours ; — and to the section on the diagnosis of cancer. As the facts detailed in the chapters in which these subjects are discussed are, like those formerly advanced, solely deduced from clinical observation, I firmly believe that their accuracy will be likewise substantiated, in the course of time, by the unanimous verdict of the profession.

* The Dublin Quarterly Journal, August, 1846. t Ibid., February, 1847.

PREFACE. 5

It may be considered an axiom, that when once a discovery in science or art has been clearly pointed out and demonstrated, it ought to be susceptible of easy confirmation, wherever and by whomsoever the attempt be made, provided the inquirer possess sufficient knowledge and skill to qualify him for the task which he undertakes, and provided, also, he carefully and conscientiously follow the rules and directions laid down by the discoverer. No alleged discovery that will not bear this test can be accepted as such ; and no person who claims the merit of a discovery ought to object to its being applied to his assertions.

I can have no hesitation in submitting the views and opinions which I entertain respecting the pathology of uterine disease to the above test. If others, employing conscientiously, in similar cases, the same means of investigation as I have done, and as carefully as I have done, do not arrive at the same results, — however contrary those results may be to the recognised opinions of ages, — I will submit willingly to their repudiation of the doctrines advanced. I have, however, no fear on this score, for they are the expression of facts truly observed and faithfully reproduced, and will hold good alike in all climes, in all lands, and in all grades of social life.

Cambridge Square, Hyde Park, March 26, 1849.

PREFACE

TO THE FIRST EDITION

During my connexion with the Paris hospitals, which lasted seven years, three as a pupil, and four as a resident medical functionary, owing partly to choice, and partly to fortuitous circumstances, I was the assistant of several of the physicians and surgeons of that capital who have paid the greatest attention to uterine pathology, and my attention was thus early directed to this interesting department of medical knowledge. As I generally availed myself of the privilege granted to Paris " internes" by the hospital authorities, to take private clinical pupils with them on visiting the patients entrusted to their care, I was compelled to analyze carefully the morbid phenomena of every case, so as to satisfy the inquiring disposition of men of mature age and understanding, whom alone I could take with me, owing to the peculiar nature of uterine maladies. I was thus soon led to perceive, that however carefully the field of uterine pathology had been investigated, there still remained much to be elucidated. One point more especially attracted my attention — viz., the nature, causes and therapeutics of ulceration and induration of the neck of the uterus, the commonest of all uterine lesions.

On referring to the most esteemed works on uterine diseases, both French and English, I found that the data which the former contained respecting this malady were insufficient to account for the numerous modifications which I daily witnessed, whilst the latter were nearly completely barren on the subject. After much doubt and uncertainty, I at length arrived at views which appeared to me to explain much of that which had heretofore been obscure. It was not, however, until the experience of one year and of one hospital had been corrected by that of other years and of other hospitals, that my ideas took the direction which is presented in the present work.

To render this statement intelligible to those who are unacquainted with the medical institutions of Paris, I may mention that that city is o PREFACE TO THE FIRST EDITION1.

remarkable for the extent and number of its special hospitals. There are immense separate establishments for the young, the adult, and the aged, as also for the syphilitic, the scrofulous, and those affected with skin diseases. Into these the house physicians and the house surgeons (who hold their appointments for four years) are successively draughted, so that, in the six or seven years during which the Paris " interne's" connexion with the hospitals lasts, at first, as a pupil, and subsequently as a resident functionary, disease is studied on a large scale, in very varied fields. These successive changes of the point of view from which pathology is seen, I found of the greatest possible use. Uterine disease is not the same at St. Lazare, where five hundred female prostitutes, affected principally with primary syphilis are treated as it is at the Hopital St. Louis, the receptacle for cutaneous syphilis and scrofula, or as at the general hospitals, where non-syphilitic patients are recieved. Even in the latter, great differences exist ; some — such as La Pitie — being near La Maternite, where several thousand women are delivered annually, receive many patients recently discharged from that hospital; others — such as La Charite and the Hotel Dieu — depend more on the general population ; whilst in the Salpetriere, which contains three thousand five hundred women above sixty years of age, and several hundred incurable cancerous patients, the uterine field again changes. I do not mean to say that the same forms of disease are not met with in these various establishments, — for such an assertion would be erroneous, — but that the proportions in which they show themselves and often, the modes of their manfestation, differ considerably.

An outline of my views on the subject of which I am about to treat, was hastily sketched and presented to the Faculty of Medicine of Paris, in the form of a thesis, on my graduating at that university. The present more elaborate essay was published, in parts, in the ' Lancet* of this year ; and as I think the facts and views which it contains are of importance, I now reproduce them in a more extended and complete form. Under such circumstances, I cannot, certainly, be reproached with not having matured my opinions. In the first instance, they were formed after I had long enjoyed very great opportunities for seeing uterine disease. They have since been considered over and over again, and have stood the test of several years' additional experience.

Some of the views which I bring forward will, I believe, be found original, — at least, if I can trust the results of my bibliographical researches. I have also many details of great interest and importance to present, with reference to the various modes of treatment in inflam-

Preface To The First Edition. 9

mation, ulceration, and induration of the uterine neck adopted by the Paris physicians and surgeons — details which will, I believe, be new to most of my readers. Having carefully watched, during a great length of time, the effects of the treatment followed by the eminent Parisian practitioners, with whom the knowledge of this form of disease recently originated, and that under the most favourable circumstanoes — as their pupil or assistant — I have been able, I hope, to form a correct estimate of the comparative value of the different agents which they employ. I have thus, I am also inclined to think, learnt how to avoid the exclusiveness which most of them show in the choice of their therapeutic agents.

In Paris hospital practice, the objections which exist in Engl and 'to examination by the touch or by thespeculum, either are not met with or are not allowed by those physicians and surgeons who pay special attention to uterine disease ; consequently, little more difficulty is experienced in appreciating, by their means, the symptoms furnished by the uterine organs, than in resorting to any usual means of investigati on in diseases of other parts ofthe economy.

This being the case, the opportunities for investigating the state of" the internal organs of generation in females presenting uterine symptoms must necessarily be much greater than in England, where no examination, even of a married person, is attempted by the most experienced practitioners, unless .there be very serious reason for such a step, and very frequently not even then. That this laudable sense of propriety is, however, often carried much too far by the members of the medical profession with us, is well known to all who specially study uterine pathology. I might mention numerous illustrations of this fact. One alone, however, will suffice to show how frequently examination is neglected by well-informed practitioners, from false delicacy on their part and not on that of their patients.

A few months ago, I was consulted by an unmarried female, who had presented for eight years, not a few only, but all the symptoms of uterine polypus. During this period she had been attended, for weeks and months at a time, by five or six different medical gentleman, of undoubted talent and ability, not one of whom ever proposed an examination, although, from the intensity of the symptoms, they must have suspected the nature of her disease. This person has repeatedly told me she would at any time have submitted to an examination had she been requested, so great were her sufferings. Delicacy carried to such an extent becomes absolutely criminal, and, moreover, reflects discredit

10 PREFACE TO THE FIRST EDITION.

on the profession, the patients attributing to ignorance, as in the case alluded to, the excessive scruples of their medical attendants.

I have been often told that females in this country will not' submit to treatment when afflicted with uterine disease. I can only say that I have not found this to be the case in my own practice. I have met with many objections, but never with a decided refusal, when I have stated that an examination was imperatively necessary. I am, indeed, convinced that our countrywomen, when suffering under these distressing diseases, would always submit to an examination — conducted with a due regard to their feelings — were the absolute necessity of such a step properly enforced by their medical attendant. Health and life are too valuable for every possible sacrifice not to be made when they are endangered.

It may be as well to mention here, that the cases which are interspersed throughout this work are not given to substantiate my opinions, but merely to illustrate them. There is nothing more tedious to a reader than the perusal of a long series of cases, all reproducing the same phenomena ; and when the doctrinal points brought forward are deduced from plain every day facts, — which are not generally appreciated, merely because they are not sought for, — it is quite unnecessary to parade a long array of cases in order to substantiate them.

Cambridge Square, Hyde Park, June 18, 1845.

Chapter I. Pagb

Preliminary remarks. — A new field opened to the study of uterine disease, by the adoption of physical means of investigation. — The facts recently brought to light known to the ancients. — The state of medical science and practice in the middle ages, the cause of modern ignorance of uterine pathology . 13

CHAPTER n.

Anatomy and physiology of the uterus. — The extreme frequency of peripheric uterine inflammation. — Real statistics of uterine diseases. — The reputed functional disorders of the uterus generally the result of local inflammation. — Division of the subject 19

CHAPTER lit.

Metritis. — Inflammation of the body of the uterus in the non-puerperal state. — Acute metritis — Chronic metritis. — Internal metritis . . . .28

CHAPTER IV.

Inflammation and abscess of the uterine appendages, ovaries, Fallopian tubes, and cellular tissue. — Inflammation and abscess in the non-puerperal state. — Inflammation and abscess in the puerperal state 47

CHAPTER V.

Inflammation, ulceration, and hypertrophy of the neck of the uterus. — Division of the subject. — Inflammation, ulceration, and hypertrophy of the cervix uteri, considered generally 67

CHAPTER VI.

Inflammation and ulceration of the neck of the uterus in the virgin female. — Its connexion with leucorrhea, dysmenorrhea, amenorrhea, irregular menstruation, partial prolapsus, &c 112

CHAPTER Vn.

Inflammation and ulceration of the neck of the uterus during pregnancy. — Its influence as a cause of laborious pregnancy, hemorrhage, obstinate sickness, death of the foetus, moles, abortion, &c 132

12 CONTENTS.

CHAPTER VIII.

Inflammation, ulceration, and induration of the neck of the uterus, during, and after, abortion and parturition. — Its connexion with rigidity of the os during labour, with laceration and abrasion of the cervix, wiih flooding, and with the morbid symptoms that follow natural and difficult labour . . 152

CHAPTER IX.

Inflammation and ulceration of the neck of the uterus in advanced life, after the cessation of menstruation

CHAPTER X.

Inflammation and ulceration of the neck of the uterus, accompanying uterine polypi, and fibrous tumours of the uterus 167

CHAPTER XI.

Inflammation of the vagina and vulva 179

CHAPTER XII.

On the connexion between inflammation of the uterus, or its neck, and functional derangements and displacements of the uterus. — Leucorrhea ; amenorrhea ; dysmenorrhea; menorrhagia, and uterine hemorrhage, generally; sterility, abortion; prolapsus, ante version, retroversion, retroflexion; chlorosis, hysteria 183

CHAPTER XIII.

Syphilitic ulcerations of the neck of the uterus 209

CHAPTER XIV.

On the diagnosis of cancer of the uterus 221

CHAPTER XV.

TREATMENT.

On the treatment of inflammation of the uterus, its neck, and its appendages . 249 The treatment of inflammation of the neck of the uterus .... 250

The treatment of acute metritis 308

The treatment of chronic metritis 309

The treatment of internal metritis 315

The treatment of inflammation and abscess of the uterine appendages . .317

Appendix

On the physical examination of the uterus and its appendages . . .321 Synopsis of three hundred cases of uterine disease, treated at the Western General Dispensary • 329

A PRACTICAL TREATISE ox

INFLAMMATION OF THE UTERUS,

CHAPTER I.

PRELDILNARY REMARKS,

A NEW FIELD OPENED TO THE STUDY OF UTERINE DISEASE BY THE ADOPTION OF PHYSICAL MEANS OF INVESTIGATION — THE FACTS RE- CENTLY BROUGHT TO LIGHT PARTIALLY KNOWN TO THE ANCIENTS

THE STATE OF MEDICAL SCIENCE AND PRACTICE IN THE MIDDLE

AGES THE CAUSE OF MODERN IGNORANCE OF UTERINE PATHOLOGY.

Among the various branches of the healing art over which light has latterly been thrown, by the application of physical means of examination to the appreciation of local symptoms and of morbid changes, uterine pathology stands preeminent. The recent adoption, by some leading continental practitioners, of careful instrumental examination in the diagnosis and treatment of diseases of the uterus, has opened an entirely new field to practice, and must lead to a complete transformation of uterine pathology, as it is now presented in the medical literature of this country.

The discovery of percussion and auscultation, by Avenbrugger and Laennec, has not, indeed, produced as great a change in thoracic par thology, great as that change has been, as the application of physical examination in uterine disease is destined to effect in this important and extensive department of medical science. That I am not attributing too much weight to the results attainable in this branch of medical science by the discovery of improved means of diagnosis will, I feel certain, be admitted by all who carefully peruse the following pages, and who recollect that the views which they unfold, although 2 contrary to generally received opinions, are the scrupulous deduction of clinical observation only, and not the offspring of theoretical reasoning.

To those who have studied uterine disease in the most recent and most esteemed works that have appeared in this country, the views and assertions contained in the present treatise will probably appear exaggerated ; but all who take the trouble practically to test their correctness, will most certainly find that I have neither exaggerated nor misstated. The great error committed by all who have hitherto written on uterine affections, with the exception of some recent French authors, consists in their looking upon and describing inflammation of the uterus as a rare disease in the non-puerperal state, whereas, in reality, inflammation is the commonest of all the morbid manifestations of that organ, as it is of all other organs of the animal economy. As a necessary result of this error, not only is the existence of inflammation itself unsuspected and overlooked, but many morbid states which it gives rise to are also misunderstood, and generally, if not always, studied independently of their origin : among these I may mention, leucorrhea, dysmenorrhea, monorrhagia, partial prolapsus of the uterus, general debility, &c.

At first sight, it certainly does appear singular, to say the least, that a class of diseases of such every-day occurrence as uterine inflammations in reality are, should have been almost totally overlooked until within the last few years, and that the symptoms which they occasion should for ages have been made the foundation for false pathological superstructures. Such, however, is the case; successive centuries have perpetuated the same errors, and that owing to causes which are easily explained, if we revert to the past history of medicine.

The uterus is an organ to which is entrusted the preservation of the species, and not of the individual of whose organization it forms a part. It has, consequently, no hourly, daily, function to perform, like the brain, the lungs, the liver, the interference with which by inflammation necessarily gives rise to a class of decided, unmistakable symptoms. Moreover, inflammation of the non-impregnated uterus, owing to anatomical data, into which I shall presently enter at length, is generally peripheric, if I m&y use the term ; that is, it is principally confined, at its origin, to the mucous membrane covering the cervix and lining the cavity of the cervix, to the cervix itself, which is much less sensitive than the body of the uterus, to the cellular tissue lying between the peritoneal folds that constitute the lateral ligaments, and to the ovaries. When affecting the mucous surfaces mentioned, its most frequent seat, it is, likewise, generally chronic. The operation of these physiological and pathological facts, combined with the concealed and central anatomical situation of the uterus itself, gives to the symptoms of the vast majority of uterine inflammatory affections, a degree of obscurity which those of few other diseases present. Hence the necessity of calling to our aid, in order to form a true diagnosis, every possible means of assistance ; and certainly, no mode of investigation is so likely to enable us to arrive at a correct knowledge of the morbid changes which are taking place in a concealed organ as the ocular inspection of the organ itself.

That such an inspection is not only possible, but in most cases perfectly easy, was, no doubt, discovered in a very early period of medical history. We continually see the uterus falling, by its own weight, or by the laxity of its means of support, to such an extent as to merely require the separation of the labia to be seen, or as even to protrude externally. From the examination of the womb thus prolapsed to the use of some mechanical means of opening the vulva and vagina, so as to allow the eye to reach the lower segment of the uterus when the organ is not prolapsed, there is but a step. That step was made probable more than two thousand years ago. Although the fact is not generally known, it is nevertheless quite certain that ocular inspection of the cervix uteri by instrumental means was known to the ancients, perhaps from the earliest times ; and its having subsequently fallen into complete abeyance, along with the information obtained through its means, is a most singular fact in the history of medicine, one which can only be explained by the peculiar social conditions through which medical science has since passed.

Paulus JEgineta alludes to the Siotttocc^ or dioptra, in several parts of his work, as to an instrument in general use. In the section on ulceration of the uterus,* he states that the ulceration is to be detected by the dioptra ; and in that on the treatment of abscesses of the womb,f there is a long account of the way in which the instrument, evidently a kind of bivalve speculum, is to be used. This well-known author lived in the seventh century, but he was more a compiler than an original writer, and, according to Mr. Adams, the learned translator and commentator of his works, this part of his description of uterine diseases is mostly taken from Aetius, who, in his tnrn, professes to have copied from writers who lived at a much earlier period, such as Archigenes and Asclepiades.

Not only was instrumental examination of the uterine neck known to the ancients, but they were evidently quite familiar with this mode of investigation. This fact is satisfactorily proved by the practical information respecting diseases of the cervix uteri which they possessed, information which they could only have acquired by the ocular demonstration afforded by the use of the speculum. Thus, in the section of Paulus iEgineta's works on " Ulceration of the Womb," to which I have alluded, J we find inflammatory ulceration of the cervix

* The Sydenham Society's edition of the works of Paulus ^Egineta, vol. i. p. 624.

t Sydenham Society's Paulus iEgineta, vol. ii. pp. 385-6.

\ Ibid , vol. i. pp. 624, 5 : — " The uterus is often ulcerated from difficult labour, extraction of the foetus, or forced abortion or injury of the same, occasioned by acrid medicines, or by a defluxion, or from abscesses which have burst. If, therefore, the ulceration be within reach, it is detected by the dioptra, but if deep-seated, by the discharges ; for the fluid which is discharged varies in its qualities. When the ulcer is inflamed, the discharge is small, bloody, or feculent, with great pain ; but when the ulcer is foul, the discharge is in greater quantity, and ichorous, with less pain. When uteri, its causes, varieties, and treatment, described at some length. The description is rather confused, it is true, but it is impossible not to recognise in it the various pathological facts which have been resuscitated these last few years. The writers were clearly acquainted with the various inflammatory lesions of the cervix uteri, which in reality constitute, as I have stated, the commonest forms of uterine disease, and must have been in the habit of guiding their treatment by the state of the cervix as revealed by the dioptra. It is thus that we find different agents recommended according as the ulceration is " clean or foul ; spreading or not spreading ; attended or not with inflammation." It does not appear that caustics were used, the treatment enjoined being that resorted to by the ancients in the treatment of ulcers generally, and consisting, rationally enough, in two classes of agents, emollients and astringents.

It is impossible for any one acquainted with the modern state of medical literature on this subject to read without surprise the description of ulceration of the womb, which I have extracted from Paulus JEgineta. The important facts which it sets forth, although of every-day occurrence, appear to have fallen into complete oblivion for centuries, until M. Recamier, one of the present physicians to the Hotel Dieu in Paris, fortunately for humanity, revived the use of the speculum, and by its means resuscitated the knowledge so long dormant.

I cannot, indeed, better illustrate how totally the important pathological data which it will be my aim to elucidate had been lost sight of, than by recalling the very singular fact, that inflammatory ulceration of the uterine neck and its sequelse are not even alluded to in the work which for the last thirty years has been considered the standard authority on uterine diseases, and whose talented author occupies the very first rank among our uterine pathologists. I allude to Sir Charles Clarke's Treatise on Female Discharges, the third edition of which was published in 1831. The various forms of cancerous ulceration are carefully described, but the very existence of inflammatory ulceration is not mentioned. Now when we reflect that, as I shall hereafter show, in nearly five cases out of six of uterine disease, in which chronic discharges, mucous, puriform, or sanguinolent, or other uterine symptoms, are present, there is inflammatory ulceration of the cervix, it is easy to conceive how erroneous must be the views respecting uterine pathology of a medical school ignorant of so vitally important a fact.

the ulcer is spreading, the discharge is fetid, Mack, attended with great pains, and other symptoms of inflammation ; irritation is produced by relaxing medicines, and relief by the opposite class. When the ulcer is clean, the fluid is small in quantity, consistent, without smell, thick, white, with an agreeable sensation. When the ulcer is inflamed, we must use those things recommended for inflammations. WThen it is

foul the Egyptian ointment without the verdigris answers admirably for the

cure of ulceration when the ulcer is spreading and attended with inflammation when the ulcer spreads and is without inflammation

when the ulcer has become clean."

The surprise which we cannot but feel on learning that so much valuable information respecting female diseases was lost to humanity for so lengthened a period, diminishes, however, when we reflect on the channels through which the knowledge of the ancients has been conveyed to us. When Europe was plunged in the intellectual darkness that followed the overthrow of the Roman empire by the barbarians, Science found a refuge among the Arabs, and it was through their labours, principally, that the Greek and Roman medical classics were preserved, and became known to their successors in science, the Roman-catholic priesthood.' On what is called the revival of letters taking place, several centuries after the overthrow of the Arabian caliphs, all the knowledge of the day, medicine as well as the other arts and sciences which constituted the Quadrivium, was confined to the priests and monks.