Page images
PDF
EPUB

the beginning. As dilatation and softening of the uterine walls are only required for its production, it is found, not only after delivery, but also in women who have never borne children-e. g.—after the sudden removal of a polypus from the fundus uteri; and the affection may be produced, not only by traction, but by the compression of the upper portion of the enfeebled walls of the uterus, by the weight of the intestines, and the contraction of the abdominal muscles.

It is surprising how little suffering an affection, usually so formidable, produces in some cases. The author relates a case of an old woman who died of bronchitis in the Salpêtrière, and upon the examination of whose body most complete inversion of the uterus was found. Convalescent from a former attack, she had been under observation a considerable time prior to the fatal seizure of bronchitis, and was observed to be very active in her habits, regular in most of her functions, and manifesting no one symptom whatever of uterine derangement, and the inversion was discovered after death, as it were, by accident. As a general rule, however, those women who do not perish forthwith drag out a miserable existence. M. Lisfranc does not believe in the authenticity of those cases, in which the uterus is said to have been reduced spontaneously or by art, at the expiration of days, weeks, or even months after the inversion has occurred.

Prolapsus of the Uterus.-Upon the effect of engorgement or hypertrophy of the uterus in inducing this, the author thus remarks.

"Displacements of the uterus are astonishingly frequent. I have demonstrated this fact too frequently to my clinical class at La Pitié for it to be doubted. But it is generally believed that these affections are almost always essential (primary). I am not of this opinion, and it has caused grave errors in therapeutics to be committed; for, on admitting it, the descent, or deviation of the womb is alone treated, and the uterine engorgements are neglected until they become incurable. I have advanced elsewhere that I will prove, whenever it may be required, that the descent, prolapse, anteversion, retroversion, and lateral inclination of the uterus, are excessively rare, when this organ is exempt from hypertrophy. For more than fifteen years I have especially directed my attention to this important point of pathology. I have examined thousands of women, and, to the present time, I have found some few cases only in which these morbid affections existed without a sensible increase in the size of the uterus. When the uterus is engorged in its entire circumference it descends parallel to the pelvic axis: if its increase of volume prevails in front there is anteversion, and the contrary when such augmentation occurs at the posterior portion of the organ. Lastly, when the induration exists upon one side, to that side it inclines. It requires but the simplest knowledge of physics to perceive that a pyriform body, somewhat flattened, suspended in the pelvis by four supports, must, if its anterior portion acquires a considerable thickness, execute a movement which will carry its superior portion towards the symphysis pubis, and vice versa.

"But I have often heard the following question asked by men who object to these new ideas. Is this hypertrophy, which is observed in displacements of the uterus, primary or consecutive?' If it followed the displacements it is evident we should very frequently meet with these affections alone, for, before the development of the engorgement, the patients would suffer pain, and in examining them we should find such engorgement absent; but essential displacements being in fact exceedingly rare, every one must admit their production by the hyperNo. LXXVIII.

G G

trophy. If required, there is still another proof in favour of this opinion. The engorged womb is displaced-I confine my treatment simply to the engorgement. I cure it, and the organ shortly after resumes its natural position in the pelvis. "These statements are neither idle nor merely curious. Every one, reflecting upon the subject, must see that it is not a matter of indifference whether we exclusively treat any displacement of the uterus, or whether we attack an engorgement of that organ." 409-11.

The engorgement, in fact, must be the primary object of treatment, and, if degeneration of structure has not occurred, may often be effectually relieved. The pessary must be delayed until this is subdued, and may not even then be required.

In reference to the irritation of the bladder, so frequently prevailing when the uterus is displaced, M. Lisfranc observes—

"This inconvenience is especially found in pregnant women. An advantageous means of facilitating the expulsion of the urine is to pass the finger into the vagina behind the pubes, and thus relieve, for the time, the neck of the bladder and urethra from the pressure which the uterus exerts upon them. The patients easily perform this manœuvre for themselves.

"Women are also often tormented by excessively frequent desire to urine, so that, especially about the menstrual periods, they have to rise sometimes 15 or 20 times in a night. Topical emollients and narcotics occasionally produce excellent effects. I have great confidence in the following remedy, founded upon the great success that has attended my use of it, conjoined with derivative bleeding from the arm. A small lavement, nearly cold, is administered night and morning, containing a few grains of camphor, suspended in yolk of egg, and a few drops of Sydenham's laudanum." 429.

Retroversion of the Uterus.-This is more common than the prolapse, but not so much so as the anteversion of the organ. Its usual source is engorgement, and it may occur suddenly or come on slowly. Pelvic tumors often cause or increase the displacement; they can be traced in contact with the uterus, and yet are distinct from it, as the non-effacement of its cervix proves among other marks. The replacement of the uterus is painful and difficult, and yet not permanent. When it occurs during pregnancy, the development of the womb is often interfered with, and abortion may be produced. It may exert most injurious pressure upon other organs, and especially upon the bladder, giving rise to retention of urine, difficult frequently of relief, and yet, if not relieved, leading to gangrene or rupture of the bladder. Violent tenesmus is also present, and the woman is tormented with most urgent expulsive efforts, sometimes forcing the womb far beyond the external parts. Before any attempts at reduction are made, all inflammatory action must be relieved, when, indeed, the organ will frequently return to its normal position. Where this is not the case, the author furnishes us with the mode of procedure for effecting the reduction.

Anteversion of the Uterus.-In this (the converse of the preceding) we have the fundus of the uterus directed towards the pubis, pushing the bladder downwards and forwards, and its cervix lodged in some portion of the concavity of the sacrum. It is usually said to be less frequent of occurrence than retroversion, but this is only the case when the uterus

contains the fruit of conception. In the empty state of the organ the deviation now under consideration is infinitely more common. The anterior face of the womb is more exposed to external injury, and consequent congestion. The habit women have of frequently emptying the bladder, also, allows the uterus, already disposed to do so by its weight, to descend in front. The habitual constipation of the Parisian women is another cause-the fæces being detained, as may be felt on examination, for some time opposite the junction of the neck and body of the

uterus.

True anteversion is very rare in pregnancy. The symptoms and examination, when carelessly made, have sometimes led to the belief of the existence of an affection of the bladder rather than one of the uterus. This displacement usually comes on slowly, is less complete and less serious than retroversion, for its reduction is much easier.

Inclination or Obliquity of the Uterus.-This may arise congenitally from faulty conformation of the pelvic cavity, from constipation retaining the fæces above the cervix uteri, pelvic tumors, unequal length of the pelvic ligaments, &c.; but, when it occurs independently of pregnancy, it is usually caused by lateral engorgement of the uterus, or the presence of fibrous tumors. The author recommends early manual interference for the purpose of directing the os uteri towards the centre of the pelvis, and the due attention to the position of the woman during pregnancy.

Means of counteracting Displacements and Engorgements of the Uterus.

-

Sponges. These must not be employed until all inflammation and pain are subdued, and, even when these are absent, they sometimes cause great suffering, compelling their removal, although the woman may have kept very quiet, and taken narcotics. But they frequently occasion great inconvenience at first, and yet must not too hastily be withdrawn; for the patient, becoming shortly accustomed to them, ceases to suffer. Indeed, neuralgic pains are often dissipated by the sponge, and it may sometimes be employed with advantage when we are in doubt as to the exact nature of the pain which exists. It must be frequently removed and cleansed, or it will give rise to inflammation and ulceration of the parts with which it is in contact. Sponges are useful in a relaxed state of the uterus, or of the utero-vulvar membrane, and in the early stages of the uterine displacements, but are quite inoperative against complete prolapse.

Pessaries. Many women have the greatest repugnance to the employment of these, so as to render delay in their use imperative. Although some painful and irritable conditions of the vagina may be relieved by pessaries, as a general rule they become aggravated by them. In cases where no suffering pre-existed, very much is sometimes induced by these instruments. The existence of an abundant leucorrhoea, when not of an inflammatory origin, does not contra-indicate their use.

After the first application of the pessary the female should observe the recumbent posture for five or six days or longer, lying on a sofa, or long chair, preferably to a bed, the heat of which produces congestion of the

genital organs. Exercise must be only very gradually resumed. When the instrument excites great irritation, some blood should be abstracted, emollient injections and anodyne lavements administered, light diet adhered to, and a luke-warm anodyne cataplasm laid upon the belly. If the irritation does not subside, the instrument must be removed.

The pessary should be removed every 15 or 20 days, cleansed, and reapplied immediately; and when much suffering results from its use, we should carefully examine, to ascertain whether this arises from its having shifted its proper position, so as to require re-adjustment. The author enters into long detail of the different varieties of pessary.

Pessaries, which have been allowed to remain in the vagina for months or years, sometimes become so impacted, as to require dangerous ope rations for their removal. At other times, they penetrate the walls of the vagina or rectum, and excite acute inflammation or typhoid fever. When they excite inflammation in the textures they are in contact with, their removal is called for; but the question arises, whether this should be effected at once. This was M. Lisfranc's practice at the commencement of his career; but, having found the process of removal much aggravate all the sufferings of the patient, he subsequently put into force the antiphlogistic treatment prior to attempting it. When the pessary projects much towards the rectum, as it so frequently does, it is best removed by manœuvres made within the gut. When pessaries cannot be borne, small bags may sometimes be introduced into the vagina and subsequently inflated. Frequently the patient is cured, and the negligence of her attendant prevents his ascertaining that the pessary is no longer required, and thus it is often needlessly and injuriously retained.

Redness, Pimples, Aphthæ, and Granulations, situated on the Cerviz Uteri.-The posterior lip of the os uteri is especially liable to these. Patches of redness, separate or confluent, are often found, especially when uterine leucorrhoea is present. Such redness is frequently found at the periods of puberty, and of the cessation of the menses; and is distinct from the normal redness observed in pregnancies and during the catamenia. Frequently no distinct symptoms are present, and it is not until the speculum is employed that a condition of parts, capable of leading to much mischief, if not relieved, is discovered. Neglected, incurable ulcers may follow. Antiphlogistic treatment is first required, and that proportioned to the acute or chronic character of the accompanying inflammation. Afterwards the fluid protonitrate of mercury should be applied, in the slightest possible manner, by means of a camel's hair pencil, to a small part only of the diseased surface. The speculum should then be filled with nearly cold water to counteract the effect of any superfluous application that may have accidentally resulted.

Non-Cancerous Ulcers of the Uterus.-These are very common in Paris, where leucorrhoea is endemic; they present every variety as regards form, size, and number, while their chief locality is the posterior lip of the os uteri. Hypertrophy accompanies and precedes the affection.

Sometimes the ulcers give rise to hæmorrhages, which must be met with depletory or derivative bleeding, and the application of the protonitrate of

.1

mercury, as varicose tumor will become developed if the case is neglected. The ulcers are frequently of very slow and insidious progress. They are frequently mistaken for cancer, offering then scarcely any diagnostic mark beyond that derived from the success of treatment. This consists of antiphlogistic and soothing means until active inflammation has become dissipated. Injections of various kinds may then be used, and the iodide of potassium administered. In this way ulcers of bad aspect may often be cured, as in other parts of the body, without having recourse to caustics. But as a general rule these are necessary for the treatment of ulcers of these parts, but they should usually be deferred until all active irritation has become subdued. Still, if the ulcer makes great progress, in spite of antiphlogistics, which is not usual, or even remains stationary for two or three weeks, the use of the caustic must not be delayed. The fluid protonitrate of mercury is to be applied, rather with the intention of modifying the vitality of the part than of producing its disorganisation, except in the cases of very deep ulceration, extensive fungosities, or suspected cancer, when its application must be more extensive. The cauterization requires frequent repetition. When the ulceration is very slight, or mere excoriation, the nitrate of silver will suffice, but this sometimes causes hæmorrhage from the sore. From three to six months are generally required for the treatment of these cases, at other times much less time; while again some require even years. Out of 50 cases, the author states he has cured 42, by cauterizing in this way; but some are so obstinate as to wear out the patient by the discharge and excessive pain they cause, and render their removal by the knife imperative.

Cancer of the Uterus.-Cancer of the uterus without ulceration is rare, for in most cases it commences by ulcers, which at first appear quite simple. Still, occult cancer is occasionally met with, may be indolent, and frequently presents no symptoms distinctive from other engorgements. It must be treated as they are, and when suspected to be cancer, care must be taken not to practise any opening into its substance.

M. Lisfranc delivers his opinion, as to the age at which cancer usually occurs, in the following terms, in which he will be found to differ from other observers.

"Cancer is not found equally prevalent at all ages. It has been said that this disease usually manifests itself between the 40th and 45th years, and that then it became less frequent in the following progression: from 30 to 40; from 45 to 50; from 20 to 30; from 15 to 20; from 50 to 60; and, lastly, from 60 to 70. The numerous women I have attended since 1815, have convinced me that cancer of the uterus attacks most especially between the ages of 18 and 35, confirming the great principle of pathology, that an organ is more liable to become diseased in proportion to the activity with which its functions are carried It is erroneous to believe that this disease is more common at the period of the cessation of the menses. I have seen a cancer occupying the cervix uteri of a young girl in her 15th year. From 70 to 80 years of age uterine cancer is very rare." 610.

on.

On the importance of early examination, the author thus expresses himself.

« PreviousContinue »