A Practical Treatise on Inflammation of the Uterus, Its Cervix and Appendages

A NEW FIELD OPENED TO THE STUDY OF UTERINE DISEASE BY THE ADOPTION OF PHYSICAL MEANS OF INVESTIGATION-THE FACTS RECENTLY 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 pre-eminent. 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 pathology as the application of physical examination in uterine disease is destined to produce in this important and extensive department of medical science. That I am not attributing too much weight to the results attainable in uterine pathology 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 contrary to generally received opinions, are the scrupulous deduction of clinical observation alone, 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 mis-stated. The great errror 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, menorrhagia, 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 may use the term; 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. It is, likewise, generally chronic when affecting the mucous surfaces mentioned, its most frequent seat. 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 probably 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 singular circumstance in the history of medicine, which can only be explained by the peculiar social conditions through which medical science has since passed.

Paulus Ægineta alludes to the Stonτpa, 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,2 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 turn, 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 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 Ægineta's work on "Ulceration of the Womb," to which I have alluded,3 we find inflammatory ulceration of the cervix

1 The Sydenham's Society's edition of the works of Paulus Ægineta, vol. i., p. 624. 2 Ibid., vol. ii. pp. 385, 6.

3 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

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A Practical Treatise on Inflammation of the Uterus, Its Cervix and ...