81

CHAPTER VI

SUMMARY.

THE DOUBLE MEDICO-CHIRURGICAL CHARACTER OF UTERINE

PATHOLOGY.

My aim in writing the Review of the opinions and theories more or less current respecting uterine pathology which I have now concluded has been twofold. Firstly, I have wished to show that the frequent existence of inflammatory lesions of the uterine neck, ulcerative and other, which I and those who preceded me in the surgical investigation of uterine diseases have announced, is a truth. That it really is a truth, an undeniable truth, I have proved, not by my own experience, or by that of the pathologists who agree with me, but by appealing to the observation and writings of practitioners who hold totally opposite opinions as to the pathological importance, and even as to the cause and nature, of these lesions. Henceforth this fact must be accepted as one established on an incontrovertible basis, and to question it will merely expose those who do so to the smile of the more enlightened members of the profession. Secondly, I have wished to show that the various theories which have been brought forward with a view to explain uterine ailment and uterine lesions, without referring to idiopathic uterine inflammation as, generally speaking, their direct cause, are untenable on scientific and practical grounds. This I have proved by demonstrating that these theories are founded on the endeavour to give a general application to facts which in reality only admit of a very partial application.

Thus, cases may and do occur in which inflammatory lesions of the neck of the uterus, including ulceration, exist without presenting any pathological importance. In some women, the

G

organic sensibility of the womb, and its sympathetic connexion with the rest of the economy, are so slight, that severe uterine disease, inflammatory or other, may exist for months or years— as in other organs-without producing either much local discomfort or much general disturbance; but these are exceptional cases. To conclude from them that inflammatory lesions in this region are, as a general rule, of no pathological importance, is to state what is, on the one hand, contrary to experience, and, on the other, contrary to the laws of general pathology, to which I have so often and so confidently appealed in the course of this Review. What would be thought of a pathologist who gravely asserted that ulcerations of the eye, the nose, the mouth, the throat, the larynx, the stomach, the rectum, the anus, the vulva, &c., were of no pathological importance?—and if they are of importance, why should the uterus, the sensitive centre of so many affinities and sympathetic reactions, be the solitary exception to a general pathological law?

Thus, leucorrhoea often exists as a mucous membrane and follicular hypersecretion, the result of physiological or pathological congestion, and may, in some rare cases, exercise a morbid reaction on health, and require treatment. But to consider this hypersecretion as the essential disease that generally produces the symptoms of uterine ailment, local and constitutional; and to look upon the recognised inflammatory lesions and reactions of uterine mucous membrane, which are so constantly found in cases of uterine ailment, as mere symptoms of this essential disease, is to ignore entirely the laws of general pathology. It is, indeed, to mingle together in inextricable confusion the cause, nature, symptoms, and sequelæ of uterine disease.

Thus, ovaritis exists both in the acute, sub-acute, and chronic forms, and when it is present, reacts of course on the uterine functions, giving rise to a regular sequence of symptoms; but to attribute to sub-acute ovaritis the cases in which tenderness, pain, and fulness of the ovarian region are found, and to look upon the coexisting uterine lesions and symptoms as merely sympathetic conditions, is simply a pathological error, the result of physiological prepossessions. It is giving to the ovaries pathologically the same pre-eminence in the female genital system

that they really do exercise physiologically—a pre-eminence to which they have no real claim.

Thus, primary and secondary syphilis are both observed in the neck of the womb, but their presence is, in reality, so rare, that even in the wards of a syphilitic hospital they are seldom observed, and they have very little to do with the uterine disease observed in town practice.

Thus, displacements of the uterus are constantly met with but, except in extreme cases, they are, in reality, of secondary importance. They often exist in the healthy without being recognised or complained of; and they often remain after the removal of disease without distress or inconvenience being experienced. Whilst in those who suffer from the symptoms of uterine ailment, they generally coexist with decided inflammatory lesions; their presence may be generally explained by these lesions; and they generally disappear by degrees, as the inflammatory lesions are cured and removed.

If I have succeeded in establishing the truth of these two propositions, the correctness of the doctrines which I have so long and so strenuously defended, and which I briefly exposed in my second chapter, must be acknowledged; and the inflammation theory, as it has been termed, must be accepted as the key to the greater part by far of the field of uterine pathology. My readers, however, are now in possession of the principal data, anatomical, physiological, and therapeutical, on which my own convictions are founded, and it remains for them to examine Nature herself, to use their own powers of observation and judgment, and thus to arrive at personal conclusions and opinions on the subject. Most sincerely do I trust that the arguments which I have adduced may lead many who have hitherto been supine to throw off the trammels of preconceived opinions, to think and observe for themselves, and thus to assist in establishing on a firm basis a branch of medicine of such vital importance to the whole community.

At present it is in

and doctrines, as Such a state of

a transition state, many conflicting opinions we have seen, dividing the medical mind. things, however, is not destined to last. The sound common sense of the practical members of the medical profession will

before very long discern the truth, winnow the grain from the chaff, and definitively settle these disputed questions, as it has settled many others. This, the future verdict of the profession, may give the palm to the opinions which I defend, or it may possibly give it to those which I criticise or condemn. In the latter case, I should only be able to excuse my error by claiming to have conscientiously brought to the study of the subject all the powers of observation and reasoning which I possess. But if, on the contrary, as I hope and believe, the views I defend are eventually triumphant, my great reward will be the knowledge that I shall have contributed, under difficulties of no ordinary kind, to the advancement of true science, and to the welfare of the human family.

Before concluding, there is one fact which I am anxious to again bring forcibly before my readers; and that is, the double, medico-chirurgical character of uterine pathology. If the views which I have developed are correct, confirmed uterine disease generally passes out of the domain of medicine into that of surgery, and requires surgical means of investigation and surgical means of treatment. The practitioner, therefore, who would successfully grapple with the difficulties of uterine pathology must, on the one hand, be thoroughly imbued with medical knowledge; and on the other, he must be well acquainted with the doctrines of surgery, and accustomed to its manipulations and operations. The publication of this essay in the pages of The Lancet has given rise to a discussion which illustrates and substantiates this fact, and also shows what are some of the difficulties against which the rational therapeutics of uterine disease have to contend. It has been stated that to use the more powerful surgical agents which I recommend to modify morbid vitality in chronic, intractable, or suspicious forms of inflammatory and ulcerative disease of the cervix, is to mutilate that organ. I can, for my part, scarcely understand how any one conversant with the doctrines and operations of surgery can apply such a term to the cautious. and prudent use of the mineral acids, of the potassa cum calce, or of the actual cautery, employed, not to destroy, but to modify morbid vitality. Nor can I understand how any such prac

titioner can write with absolute horror and dread of the actual cautery, or "white iron," which is an acknowledged, accepted surgical agent, still used and prized by many surgeons, and which would be more employed, were it not that it alarms patients. I have often seen it used, and used it myself in my early surgical days, for various diseases, and have always found it a safe and manageable agent. Indeed, this fear of the actual cautery, and of the more powerful caustics, appears to me quite puerile in a surgical point of view, if these agents really are required to cure disease. What is surgery, but the application of the knife, of caustics, of the actual cautery, or of whatever powerful agent may be required to remove or to destroy disease, or to modify vitality? Why, therefore, in plain common sense, should the application of these agents to the occasional treatment of uterine disease, be spoken of with "unsurgical horror and alarm," if they really are occasionally required? and why should they not be required in exceptional cases of uterine disease, as well as in exceptional cases of disease of the bowel, vulva, meatus urinarius, &c.?

Are

Here again we may appeal to the laws of general pathology. Once it is admitted that the neck of the uterus is liable to inflammation, ulceration, thickening, hypertrophy, and induration; that it may become the seat of unhealthy, suspicious disease, ulcerative and other; and that these diseased conditions may exist uncured an indefinite number of years,-every well-informed surgeon will allow that there must be cases which will not give way to the nitrate of silver, to astringents, leeches, &c. And if so, what is to be done with them? we to leave the patients to their fate, and confess ourselves impotent to cure, whilst we have more powerful surgical agents in our hands, agents which can cure these very morbid states? To the surgically-educated practitioner there is but one solution of this question: as long as there is a fair chance of cure, he will keep to the milder means of treatment; it is his imperative duty so to do. As soon, however, as he has ascertained that these means are insufficient, he will at once, prudently and cautiously, but without fear or trepidation, resort to the more powerful means of treatment at his command.