, •■ v.- pa:.:-:-^. •i.ts.io-'o -: ,• '.•■\'Vjn«^::"y'.ii;l'.''i.'''.'?l':1 /', .'/':«):'*('.•,,?,!''.!* < f '. ■' ,' • V/. *"" .'..'.',' •,'.■• .-.'s-uK.-r.•'.'. '■!-:> .''.n:s ■■.J-,i...i.^ ■.',:-,:"■. ■-,,♦•..:>' UNITED STATES OF AMERICA FOUNDED 1836 WASHINGTON, D. C. OPO 16—67244-1 TREATISE, FUNCTIONAL AND ORGANIC DISEASES UTERUS. FROM THE FRENJ&H OF F. DUPARCQUE, Docteur en Medecine de la Faculte, et ancien interne des Hospitaux et Hospices civils de Paris, &c. &c. TRANSLATED, WI Tp NOTES, BY JOSEPH WARRINGTON, M.D. OF PHILADELPHIA. ff,/fi6 PHILADELPHIA: DESILVER, THOMAS & CO.—253 MARKET STREET. 18 37. WP DU3+ mi Entered according to the Act of Congress, in the year one thousand eight hun- dred and thirty-seven, By Desilver, Thomas & Co. in the clerk's office of the District Court of the Eastern District of Pennsylvania. TO WILLIAM P. DEWEES, M. D. (LATE PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN. IN THE UNIVERSITY OF PENNSYLVANIA,) WHOSE LIFE HAS BEEN DEVOTED TO, AND WHOSE PHYSICAL ENERGIES ARE EXHAUSTED BY THE EXERCISE OF A PROFESSION LABOURED IN WITH DIGNITY AND SUCCESS, THE TRANSLATION OF EJUS OTorfc IS RESPECTFULLY INSCRIBED, BY HIS AFFECTIONATE FRIEND, JOSEPH WARRINGTON. Vine St., Franklin Square, Philadelphia, First month, 1837. TO THE MEMBERS OF THE MEDICAL PROFESSION. Gentlemen : Conscious of the deficiency of experience re- corded in our literature, on the important subject of Uterine diseases, I have attempted to present to you an English version of Duparcque's " Trait6 th6orique et pratique sur les Alterations Organiques, simples et cancSreuses de la Matrice," which obtained a prize in a country where pathology is so much culti- vated, and where this class of diseases is far more thoroughly investigated than in almost any other. I commenced the work merely to supply my own want of information on this subject, but upon an examination of its merits, I thought it an object worthy general perusal. This idea has been con- firmed by several of my senior brethern, by whom, vi TRANSLATOR'S ADDRESS. and particularly Dr. Dewccs, I have been induced to offer it to you. American practitioners have written so little upon diseases of the uterus, that we have been obliged to look to the industry of transatlantic observers, for results which are highly important to the physician who is engaged either in obstetric or general prac- tice. The valuable researches of Mad. Boivin, and M. Duges, have been placed within our reach, by the pen of a British translator, but I am not aware that any thing of this kind, has been undertaken in this coun- try, except by myself. While, therefore, I earnestly look to the growing talent and industry of our country, to furnish us with orginal practical suggestions and experience, I hope my example will be followed by more competent members of the profession; that thus the accumulated knowledge of diseases of the generative system, which may be acquired both by American and foreign prac- titioners, may be made available to us. I have thought it proper to introduce with the Author's Preface, extracts from the minutes of the Medical Society of Bordeaux, because they express the opinion of that body, with regard to the essay which he offered for the prize. TRANSLATOR'S ADDRESS. vji The sentiments of several of my professional breth- eren, to whom both the original and translation have been presented for their examination, may be found in copies of the letters they kindly furnished me. That the translation is entirely free from the idioms of the original, I shall not assert; but I believe I have been faithful in conveying the meaning of the author. To those who are interested in the treatment of diseases peculiar to female organism, I doubt not that the publication will be acceptable; while I trust that the general practitioner will consider it worthy a place in his library. Should it aid the inquirer, or awaken the attention of those who have not hitherto reflected much on this subject, and lead us to a more successful practice in alleviating the afflictions of Woman, and enabling her to fulfil the high offices in life for which she is destined, my object will be answered. Respectfully, JOSEPH WARRINGTON. 229 Vine st., Franklin Square, Philadelphia, First mo., 1837. RECOMMENDATIONS. From Charles D. Meigs, M.D., Lecturer on Obstetrics, and diseases of woman and children, in Philadel- phia. My Dear Sir, I have examined the manuscript translation of Duparcque, which you were so kind as to put into my hands. There can be no doubt of the value of the work, since it is a prize production; awd I am sure that the English dress in which you hav« clothed it, is such as will do credit to your taste and industry. I hope you will publish it for the benefit of the pro- fession in our own country. Yours, very respectfully, CH. D. MEIGS. Da. Warrington. July 29th, 1836. 1 .\ R ECO MM EN DATIONS. From Hugh L. Hodge, M.D., Professor of Obstetrics, and diseases of women and children, in the Univer- sity of Pennsylvania. August 15, 1836. Dear Doctor, I have looked over a portion of your manu- script, and of the book. The whole is well worthy of publication—as enlarging our knowledge of uterine complaints; and especially as furnishing practitioners in this country, information not easily to be obtained. Yours, Respectfully, HUGH L. HODGE. Dr. Warrington. From Samuel Jackson, M.D., Professor of the Insti- tutes of Medicine, in the University of Pennsylvania. My Dear Sir, I have locked over your manuscript translation of Duparcque's work on organic alterations of the womb. It appears to me, to be a very accurate translation, preserving the meaning of the author, and in a fair English style. This work meets my entire approbation. It embo- dies a mass of interesting and highly useful informa- RECOMMENDATIONS. XI tion, on a class of diseases occurring daily in practice, and which are constantly overlooked, or are unknown. It should be read by every student, and be in the library of every phyisician. With respect, Your friend, S. JACKSON. Dr. Warrington. Philad. Oct. 6th, 1836. From John K. Mitchell, M.D., Lecturer in the Phila- delphia Medical Institute, Sfc. Philad. Oct. 1836. Doctor Warrington: My Dear Sir, I have read with both pleasure and profit, the part of your excellent translation of Duparcque " Sur les alterations organique De la Matrice," which you did me the favour to send me. Although the prolific source of so many morbid evils to its possessor, and consequently so important to the professional student, the uterus is so little studied, that ignorance respecting its maladies, is among the most common errors of the physicians of this country. I believe I shall be sustained by my city-brethren in the assertion, that this want of knowledge in particular, is the cause of a very large Xll RECOMMENDATIONS. proportion of the mistakes by which female sufferings are prolonged, and female life is endangered. It is, therefore, with particular pleasure that I look for your translation of a work of so great value, in an obscure and difficult part of this neglected subject. With respect, Yours, &c, J. K. MITCHELL. AUTHOR'S PREFACE. Charged with a duty, the most important in the propagation of the human species, woman seems to purchase the privilege only by the number and gravity of the evils of which it is the source. The uterus is in fact the organ, the most immediately destined to receive and develope the new being—and it is, espe- cially whilst in its state of activity, that health is liable to exposure, and existence rendered more precarious. Though the numerous affections of the external parts of generation, the ovaries and other appendages of the uterus, may exert an unfavourable, and sometimes a dangerous influence on the economy, it is principally in the latter viscus, that the most formidable diseases of women are begun or established. These diseases have therefore engaged the atten- tion of Physicians of all times, and their history occu- pies a conspicuous place in the writings of eminent Medical authors, from Hippocrates, downward. But, it is only since pathological anatomy has illuminated the general chaos of organic alterations, that we have 2 x AUTHOR'S PREFACE. had exact ideas of the nature, character, and differ- ence of those which the uterus undergoes. Until recently, nearly all its diseases were confound- ed under the illy selected denominations of scirrhus, cancer. &c &c. Hitherto, its diseases have been very much shrouded in obscurity, and their treatment but little more than empirical. It must be acknow- ledged, however, that notwithstanding the labours of the moderns, apd their numerous experiments, much remains to be done in this department of the history and treatment of these diseases ; while there is much emulation amongst practitioners in regard to the surgical treatment which has been too indiscriminate- ly applied, wTe have too much neglected the medical means best adopted to the treatment of these organic alterations. In regard to the surgical operations, painful experience proves that those so much spoken of, are rarely crowned with success; that they are often uncertain and followed by relapse ; and that in some cases, they are either useless or not indicated. The Medical Society of Bordeaux, conscious that the example given by great practitioners, was un- friendly to the progress of the science of the chronic diseases of the uterus, and to the best interests of humanity, has laudably proposed a question for the subject of a prize,* with a view to obtain the opinions * " To establish the distinctive characters of divers engorgements, of ulcerations of the neck and body of the uterus; to exhibit the methods of treatment, which agree best with each of them, and to determine the cases which require the extir- pation of the diseased parts." AUTHOR'S PREFACE. XI of practitioners, on the different engorgements and the various ulcerations of the uterus, the particular thera- peutic means which each of these affections requires, as well as the value of the operations which have been used to remove them. I am aware that a subject of so much importance, will require much research, and that many difficulties will be found in the way in treating it properly. But, having reflected on all the cases of chronic diseases of the uterus, which have been published up to this time; having myself had occasion to see and attend a great number of cases of the kind; I hope I am in some measure qualified to make a comparison be- tween them, and deduce theoretical and practical inferences, proper to respond to the question, and thereby fill the void which the history of uterine affec- tions still presents. I found the hope of having attained this object, upon the unanimous suffrage which the Royal Society of Medicine of Bordeaux has accorded to this work, after the favourable report made by the committee it had nominated, viz.: M. M. Doumeing, Brulutour, the father, Guerin, Gintrac and Bonnet. I have endeavoured to expunge from this work those defects which the committee pointed out; I have given more development to some of the propositions which it includes, and some new considerations which were overlooked in the first compilation ; thus render- ing it more nearly complete: I have supported the theoretical and practical opinions which I had pro-. xjj AUTHOR'S PREFACE. mulcted, by some new facts. I do not presume to offer a perfect treatise to the public, but I incline to think it will not be without utility to Nosography, and that practitioners can draw from it some lights calcu- lated to direct them in the diagnosis and treatment of the chronic diseases of the uterus. I divide the work into two parts : Firstly, I examine cursorily the origin, and the predisposing and deter- mining causes of the chronic alterations of the uterus, considered in a general manner. Secondly, I endea- vour to establish the etiology, the mode of production and development of these alterations and their respec- tive degree of curability. Thirdly, I point out the means by which their material existence can be recog- nised. On this subject, there are three chapters. The second part is devoted to the particular his- tory of the chronic alterations of the uterus, which I divide into alterations under the form of engorgement, which comprehends excrescences and engorgements properly speaking, and into ulcerations. I appropri- ate the last chapter, to cancerous affections. Each of these divisions forming a chapter, will itself be subdivided into as many articles as there are species of particular alterations; thus, to the engorge- ments, properly speaking, appertain, hypertrophia, oedema, sanguineous engorgement, (which may include the forms of simple congestion) ; congestion with hemorrhage, and of acute or chronic phlegmasia. Under the denomination of hard engorgement, we include principally chronic meritis, induration and AUTHOR'S PREFACE. Xlll scirrhous; engorgement by cerebreform alteration, by melanosis, and lastly, tubercles. I admit three species of ulcerations of the uterus ; simple or benign ulcers, phagedenic or gnawing ulcers, and the carcinomatous ulcers. Like the preceding elementary alterations, the pro- found alterations which we are accustomed to rank under the collective denomination of cancer of the uterus, are presented under the form: 1st, ofhyper- sarcosis, which are either essential as the mural can- cer, or secondary as carcinomatous excrescences, and fungus haematodes. 2ndly, of tumours or engorge- ments, viz.: cartilagification, or ossification; the scirrhous cancer, properly speaking, or advanced scirrhous, simple or complicated with cerebreform or melanic alterations; the sanguine or soft cancer. 3rdly, of ulcerations, as the gnawing or phagedenic ulcer, and the scirrhous ulcer. I have devoted the last chapter to the exposition and merits of the surgical or operative treatment of the cancerous affections of the uterus in general. Extract from the Report of the Commission* It would be wrong to assert that there remains noth- ing more to be said on the symptomatic or idiopathic * Journal de Medecine pratique, ou Recueil des Travaux de la SociCte royale dc Medecine de Bordeaux, aout, 1831. XJV AUTHOR'S PREFACE. diseases of the uterus, and, to speak only of these latter, we cannot conceal from ourselves, that if their diagnosis is better known, their causes, nature, and treatment, still present much doubt and obscurity. You have felt it as well as we. It is under this impression that you have believed it right to call the attention of practitioners to the engorgements and ulcerations of the neck and body of the uterus. The selection of such a question, evinces your discernment, and your constant desire to satisfy the wants of science. It would have been difficult to propose one which offered more interest, and which was more susceptible of exciting the emu- lation of gentlemen of the profession. And, notwith- standing, the important circumstances which pre- occupy the mind, and attract us to the peaceable labours of study, men are found who have responded to your call. You should felicitate yourselves as much on having instituted this contest, as having obtained the object of it. * * ■# # # * The details into which we enter, will not give you an entirely exact idea of this work, unless we again call your attention to one of its principal points. And in the first place, we may remark, that the article which treats of engorgements of the uterus, is without contradiction, the best digested, and the most com- plete upon this matter that has been published. The author has not only shown himself skilful in explaining the causes and the mode of development of the t AUTHOR'S PREFACE. XV organic alterations of the uterus, but he teaches us moreover, how to cure them. No person before him had considered the treatment of these morbid states in a manner more rational and philosophical. The curative means which he recommends to be admin- istered, are doubtless for the most part, known and long since used; but he appreciates with a rare superiority of talent, their properties, and the periods at which it is proper to prescribe them, as well as the time during which their employment should be con- tinued. One thing particularly, which appears to us new, and which it may not be useless to remark, is the explanation which he has given of the kind of modification which sedatives produce in the economy; these medicines according to him, do not exert a special action, but reduce the exaggerated enervation of the diseased tissue to its natural state; a condition necessary in order that this tissue in losing its abnor- mal secreting faculty, may regain its physiological absorbent power. Surely we have a right to demand, whether it be true, that the remedies which have engaged our attention, act in this manner, and whether it be certain, that by diminishing the altered vitality of a part, it will be enabled to recover its absorbent faculty. But it would be wrong to suppose that such a proposition has been lightly advanced; it reposes, we can assure you, upon very curious facts, which if they do not fully confirm, lend it a very high degree of probability. This article, we repeat, gives the best, and most XV1 AUTHOR'S PREFACE. complete idea of uterine engorgements that has been published. Nevertheless, it should not be dissembled, that it leaves something to be desired in certain points. It may be objected, for example, that the engorgements of the uterus do not always depend upon an inflammation—but we are not taught to distinguish the cases in which this fact occurs, from those in which the disease proceeds from real inflam- mation. We equally regret to meet at almost every page, the words red inflammation and white inflammation. These expressions, whatever may be said of them, are improper, and afford no advantage over those now generally in use. The chapter entitled confirmed cancer, possesses much interest, and we should find nothing to subtract from it, were it not for the numerous species of can- cerous affections, which our colleague has thought it necessary to recognise. These varieties being the result of one and the same alteration, we do not see the utility of establishing them. Some are, besides, evidently superflous; and supposing, it was essential to divide cancer into species, one would be necessa- rily obliged to reject those which are here made. Amputation of the neck of the uterus, and extirpa- tion of the whole of this organ, have been for some years, the subject of a lively controversy. The partizans of these operations, regarded them as one of the most important acquisitions of modern surgery; their detractors perhaps exaggerated the dangers and AUTHOR'S PREFACE. xvii inutility of them. In this state of things, it was desi- rable that an impartial man, devoid of prepossession, should endeavour to put an end to a controversy, doubtlessly laudable in its object, but which unhappily, involved personal considerations and private interest. Our colleague has not recoiled before so difficult a task, and he has much more right to our gratitude and eulogy, as he appears to us to have done it with credit. We are constrained to make you acquainted with the plan of this work, the spirit in which it is con- ceived, the order and importance of the matters therein treated. We shall further add, that it is recommended by ingenious observations, new expla- nations, and especially a great sagacity of discussion. The author is not one of those writers who build upon hypotheses, and are lost in conjectures. A severe logician, and endowed with an exquisite tact, he generally advances nothing which cannot be sup- ported by proofs.—Remark that it is not by way of reasoning alone, that he proceeds; most of his opinions rest upon numerous facts which have come under his observation.* Few physicians have seen so many organic alterations of the uterus. He also says nothing upon the faith of others, but like a man who has observed much and perfectly.—Examine the the theory of the causes, and the mode of thedevelop- Of 65 cases that he has introduced into this memoir, two-thirds belong to himself. xyjjj AUTHORS PREFACE. ment of the engorgements of the uterus, the rules of treatment for the morbid states, the judgment bestowed upon the advantages and disadvantages of the ampu- tation of the neck, and of the extirpation of the uterus. Examine we say, the principal points of his manuscript, and you will see that, without neglecting to profit by the works of his predecessors or contem- poraries, it is almost always his proper experience and practical understanding which serves for his guide. In short, gentlemen, the work which we have just examined, is in every respect, entitled to your suf- frages. The question which you have proposed for contest, is here found resolved, as much at least as it was possible it could be, in the actual state of science. There is, therefore, reason for decreeing to its author the whole prize, and it is this your commission have the honour to propose to you. Extract from the Proclamation, read at the public annual session, Sept. 3d, 1831.* The society has received three Memoirs in response. The Memoir registered No. 3, (bearing for its motto, this phrase, extracted from the Memoir, " The greatest number of cancers of the uterus might be prevented, if the engorgements and simple ulcerations * Jour, de Med. prat, ou Recuiel des Travaux de la Societe royale de Medecine de Bordeaux. Sept. 1831, AUTHOR'S PREFACE. XIX which are the most common origin of thern, were seasonably and properly combatted,") is divided into two parts. In the first, there is an expose of the general considerations of the organic alterations of the uterus. The second part includes an exact and complete history, according to the state of our know- ledge, of the engorgements and ulcerations of the neck and body of the uterus. The author of it describes the forms, from practical experience : if he has some- times indulged in theoretic explanations, he supports them with the evidence of facts. If he is known to support, by remarkable and curious cases, the descrip- tion of the engorgements which he calls Sanguine, he has shown himself not less skilful in those of the engorgements called hard, and the observations inclu- ded in this chapter, ought especially to engage the attention of practitioners. In following this guide, we would be in the most certain way of discriminating the alterations of the simple tissues susceptible of cure, from the cancerous degenerations almost always mortal; it is of much importance to confirm the happy success of the medicines which have so well succeeded with him. The author has not shown less knowledge and noble independence in the discussion of the cases which required the extirpation of the diseased parts. He has demonstrated that these operations should very rarely be performed, and that the greatest cir- cumspection is imposed upon surgeons in those circumstances, where they may, by medicines as effi- cacious as certain, preserve the patients from those XX AUTHOR'S PREFACE. always dangerous, if not fatal operations. The work is written with care; the style simple and clear ; the cases introduced are numerous, and belong chiefly to the practice of the author. It would be difficult to find any particular fault. If some neglect in the details might be relieved, they are made up for by qualities so superior, in the whole, that the Society, well satisfied, decree the whole prize, consisting of a medal of gold, of the value of 300 francs, to its author, Dr. Duparcque, physician of Paris, corresponding member of the society. A TREATISE ON THE SIMPLE AND CANCEROUS ORGANIC ALTERATIONS OF THE UTERUS. PAUT I. CHAPTER I. ORIGIN AND CAUSES OF THE ORGANIC AFFECTIONS OF THE UTERUS. This organ is not very susceptible of diseases either acute or chronic before puberty; until this period, it has not possession of that vital activity, which suffices for the spontaneous development of various lesions in other parts, or places them in conditions which dis- poses them to be affected with diseases under the influence of exciting causes. Isolated as it were from the rest of the organiza- tion, and exerting only a feeble influence upon the different organic apparatus, the uterus is itself rarely affected sympathetically during the early period of life. Being by its anatomical position, protected from the mechanical, physical or chemical action of exterior 22 A TREATISE ON THE bodies, it is little exposed to accidental maladies, and therefore, examples of diseases, and especially of organic alterations, are extremely rare in infancy. But when the period of puberty arrives, announcing itself by a more rapid development of the whole economy, and a greater activity of all the functions, the entire life seems to be animated with a new fire, the organs of generation participate in the effect of the general movement, or indeed, it is only at this time that their existence may be said to begin. The uterus then leaves the state of inertia in which it had as it were been buried, henceforth to play an important role. Its tissue becomes permeable, extensible, and even erectile. Blood circulates more freely through it, its sensibility is developed, it becomes the centre and point of departure of sympathetic irradiations, which sub- ject to it all the acts of the economy; and these in their turn exercise influences not less important on the proper functions of this organ. From this reciprocal change of influences, result, in the woman arrived at puberty, new physiological and pathological phenomena, general and local diseases peculiar to the sex, or particular forms of affections which are common to her with man. To speak of such maladies only as affect the uterus, we shall observe that this viscus may be the seat of all kinds of vital lesions and organic alterations that occur in all other organs of the economy. This dispo- sition corresponds with the anatomical composition of the uterus, for we find it endowed with a serous system, one portion of which envelopes the exterior; DISEASES OF THE UTERUS. 23 a mucous system which lines its cavity, a cellulo-fibrous membrane, a vascular system susceptible of a great development of the lymphatic vessels, nerves derived from the cerebro-spinal and the ganglionic systems; and finally, a proper tissue of a fibro-muscular charac- ter. The uterus, consequently, may suffer all the mala- dies with which each of the tissues is susceptible of being especially affected, and which are common to each of the organic systems. In the early periods of puberty, the uterus is not always in a condition to emit the fluid that gives rise to the menstrual movement in its tissue. In conse- quence of which, a local plethora or congestion occurs, manifested by a sense of heaviness in the hypogas- trium, more or less severe pains, denominated uterine colic or uterine tenesmus, alternate chills and flushes, head-ache, difficult respiration, and sometimes hys- teric fits. This fluxionary movement having existed a few hours or days, subsides spontaneously without any discharge; it re-appears with the same symptoms at the following menstrual period, until the exhalent extremities of the vessels becoming more permeable, readily disgorge themselves. In some girls, however, this state of things con- tinues through an indefinite period; the congestion of the uterus does not completely pass off after each period, but becomes increased, the local and general disturbance acquires intensity, and medical aid is 24 A TREATISE ON THE required to prevent the dangerous consequences of this morbid state. The engorgements of the uterus may under these circumstances, take on the form of simple congestion, of acute, and particularly chronic inflammation, which may successively or simultaneously pass through all the stages of suppuration, or cartilaginous or osseous degenerations. Restricted in the degree of its action, this engorgement becomes the basis of cancerous formations in the course of some years. CASE I. Mad'lle L. presented at the age of 15 years, the exterior signs of puberty. The phenomona which prelude the catamenial discharge, were manifested for some months, at irregular periods, though the secre- tion did not take place. At every period, pains in the loins and hypogas- trium, sense of fulness, and general uneasiness were so great as to oblige her to keep her bed for two or three days. These periods subsequently, became more regular as to time, being also more intense, and of longer duration. At the 9th period, the engorge- ment assumed the character of acute inflammation of the womb—there being very violent pain in the back and hypogastric region—tension of the abdomen, vomiting, delirium, fever, &c.; these symptoms were removed by prompt and active antiphlogistic treat- ment. The menstrual periods continued to return with the DISEASES OF THE UTERI'S. 25 same train of symptoms, but with a greater or less degree of violence. She had also oppressed respira- tion, palpitations, and sometimes catalepsy. Bleeding had been found to be the most useful remedy in pre- venting increasing violence of the paroxysms. It was supposed that marriage would correct this morbid state of the uterus. This took place at the age of 20; instead, however, of affording the desired relief, the morbid phenomena returned with greater violence. In July, 1829, three years after, I was called to attend her; at this time, she could not stand erect, in consequence of the severity of pain in the loins, hips, groins, and the anterior part of the thighs. She was afflicted with the dyspnoea and cephalalgia; the pulse which beat 110, was hard and contracted ; her countenance was flushed. An examination per vaginam, enabled me to dis- cover that the neck of the uterus was short, thick, and confounded with the body of the uterus, which could be felt through the vagina, in passing the finger around the neck; the uterus appeared to be as large as at two month's of pregnancy; the mouth of the uterus was partially distended, and filled with a viscid matter. I could seize the fundus by applying the left hand above the pubes, and pushing the abdo- minal parieties towards the sacrum ; it was regular in shape, and about the size of a goose egg. The pain was greatly increased by this examination, and the patient was seized with a paroxysm of hysteria. She was bled eight oz., which was repeated at night; emmolients and baths were used. I intended to try 4 2g A TREATISE ON THE the effect of prolonged and vigorous antiphlogistic treatment, but she declined it, having been persuaded, from the ill success of all that had hitherto been done, that though her case might be palliated, it could not be cured. She had already been a patient in the Hotel Dieu, and afterward in la Charite—where it was ascertained by the introduction of a stylet into the uterine cavity, that the amenorrhoea and the train of symptoms, were not occasioned by an imperforation of the uterus. I satisfied myself of the same fact, by similar means. This case presents a remarkable perseverance of the menstrual molimen, in which the uterus did not effect the ordinary discharge—it has resulted in con- gestions, which produced a permanent augmentation of volume. It would be difficult to decide whether there was hypertrophy of the organ, or that the engorgement was owing to a plethoric state, or arose from a chronic inflammation. Her general health having remained unimpaired by these successive attacks, might lead to the conclusion that it was a case of hypertrophy of the uterus. It appears to me, that in this case, the engorgement was either accidentally developed, or arose from a peculiar organization of the internal surface of the uterus, by which it was incapable of effecting its pecu- liar secretion, and therefore could not relieve the menstrual molimen. Too strong, too precocious, or too frequently repeated excitations of the genital organs, a shock communicated to the uterus by a fall upon the hips, DISEASES OF THE UTERUS. 27 knees or feet, the use of substances calculated to excite determinations of blood to the uterus; indeed all the causes which produce a congestion, not in rela- tion with the exhalent or secretory function of the uterus, are extremely liable to produce acute, or more frequently, chronic engorgements of this organ. CASE II. Adele B. at the age of 18, having thecatamenia in abundance, slipped down a stair-case while carrying a bucket of cold water; this was in the first day of her monthly period, in which there was commonly an abundant discharge, lasting four or five days. The fright caused by the fall and the splashing of the cold water with which she was inundated, suddenly arrest- ed the discharge, and she was almost immediately seized with dull pains in the hypogastrium, as well as by rigors and dispnoea. She however continued her occupation as a domestic, though during the day, the pains in her loins became so severe, that she was frequently obliged to sit down. The breasts began to augment in volume and consistence; anorexa and capriciousness of appetite followed, as in pregnancy. At the three succeeding menstrual periods, she was obliged by the severity of the pains, to keep her bed; the breasts became flaccid, and the body emaci- ated, and the appetite completely lost. The patient experienced an insupportable tension and weight in the pelvis, particularly after she had been standing some time, or walking a little. When the fourth menstrual period arrived, I bled r)s} A TREATISE ON THE her \6 oz., and prescribed for her a bath of 29 deg. R. Next day, there was a discharge of a dark liquid per vaginam; it looked as though it had been squeezed out of the uterus, and was attended by a sort of tenesmus of that organ. This imperfect men- struation continued four days. The pains were so acute that she could not avoid shrieking, either when still or in motion. She had head-ache, fever, extreme sensibility of the hypogastrium, with constipated bowels. I directed 25 leeches to the abdomen; instead of applying them, however, the attendants kept the hypogastrium covered with emollient fomentations. Appearing to be somewhat better through the night, and the abdomen rather less tense and painful, I con- tinued the fomentations and repose. Three baths were successively taken, and every thing went on in good order: at the next period, the menses occurred spontaneously and abundantly; and the uterus has continued to perform its function since. When women indulge in iced drinks, or the like frigid substances, to an extent to impress the skin suddenly by cold, the uterus is apt to sympathize, and a sort of spasmodic stricture of its exhalent mouths, takes place. The same effect may be caused by moral emotions, the shivering of an intermittent, &c. When these causes act at the approach of the catamenia, or only at the commencement of the menstrual move- ment, the effect is not only to prevent the flow, but also to obviate the congestion which precedes it; there is then only an amenorrhoea, without affection of the uterus for that time. But when the menstrual DISEASES OF THE UTERUS. 29 molimen is in full activity, to the suspension of the flow, are superadded certain local phenomena, which indicate a morbid state of the uterus. This is what happened in the subject of the preceding case. It is of much importance to know, that in this state of things, amenorrhoea is not the disease, but a symp- tom, and sometimes the consequence of an uterine lesion. Medicines of a stimulating nature termed emmenagogues, having for their object, to excite or increase the uterine congestion, can under these cir- cumstances, be no other than highly prejudicial. Bleeding, emmollients, and baths, are the best means to dissipate congestion, or restore the uterus to its natural condition, and consequently to dispose it to resume its habitual functions. CASE III. Mad. G----, 28 years old, has been married three years, and had no children. Since her marriage, she has been subject to frequent pains in the loins. March 30, 1826.—Attacked with fever, commenc- ing with violent rigor. 31st.—Apyrexia—in the evening, head-ache, nau- sea, increase of pain in the loins, slight leucor- rhcea; all of which are the usual symptoms of the approaching irruption of the menses in this lady. April 1.—The menses appeared at day-break, but in smaller quantity than at the preceding periods. 2d.—Violent chills followed by two paroxysms of fever—the menstrual flow is suspended. gO A TREATISE ON THE 3d and 4th, A pyrexia.—On the 5th, a slight dis- charge— (Sulph. Quinine, 24 grs.) No paroxysms followed, but the patient complained of an unusual feeling of weight in the lower part of the abdomen—dull pain in the hypogastrium—numb- ness and feebleness in the lower extremities. The quinine was suspended on the following day. 26th.—The paroxysms return every 4th day. May 3d.—Increase of pain in the hypogastrium and sacrum; tension in the pelvic region,—with a small discharge of serous blood. The quinine was again resumed, and continued almost a month in gradually diminished doses. There was no return of the fever, still the patient did not regain her strength; an unnatural feeling of constraint, pain and weight in the limbs, obliged her to change her posi- tion constantly. The conjugal embrace was accom- panied by severe pain, and followed by inexpressible distress for many days. There was an almost inces- sant discharge from the vagina; being somewhat increased at the menstrual periods. She lost her colour, became emaciated, and greatly distressed, by frequent attacks of gastralgia and dyspepsia. Ascribing her bad state of health to the defect of the catamenia, she used various remedies recom- mended by herbalists and old women; till finally wearied out with her suffering, she placed herself under my care, on the 20th of April, 1S27. Nearly a year had elapsed since her first attack of quartan fever appeared; and from this period, were dated the sufferings in the side of the pevlis. DISEASES OF THE UTERUS. 3 \ I found the uterus very low in the vagina; its neck thick, hard, but equally engorged; its body appeared to be larger than natural. I had her bled three times; at first, 16 oz., and at the two last operations, from 8 to 10 oz., (emmollient cataplasms, baths every day, horizontal position.— Milk with barley water and chicken broth, her sole diet.) The pains diminished, the uterus resumed its nor- mal position, but the engorgement continued.— Meanwhile the symptoms were not aggravated; at the menstrual period, (4th of May,) the discharge was rather more abundant and of longer duration. She was bled twice during the first two weeks in this month. Notwithstanding the very vigorous use of other therapeutic and hygyenic means, the uterus diminished very slowly in volume. I then resolved to try frictions in a manner calculated to excite an action upon the system, in consequence of its being absorbed. See cases 57, 59 and 61. Half an ounce of tartarized antimony was used in this way. Towards the end of May, the neck of the uterus was diminished one half, was more elongated and soft; the menses were abun- dant on the 31st of May, a few days earlier than usual, without any pain as at the former period. From eight to ten oz. of blood were taken from the arm on the 15th of June : patient is able to set up part of the day, and walk a little about her chamber: takes a little solid aliment: baths and cataplasms are continued. The catamenia appeared without incon- venience on the 2d of July, since that time they have • >., A TREATISE ON THE been but little deranged. She has, for a long time taken my advice, to abstain from sexual intercourse from danger of relapse. At page 20 of the 1th Vol. Nouv. Bibleoth. Medical, 1829, an equally remark- able case of metritis may be found, with considerable engorgement of all the organs, arising from the rigors of an intermittent fever supervening upon an accouch- ment. CASE IV. A beautiful Jewess, 15 years old, had menstruated regularly for some months; at each period, violent pains in the hypogastrium preceded the discharge, and disappeared when it was established; it generally continued pretty freely for five or six days. This state of things existed on the 12th of April, 1824, when she was suddenly frightened by an explosion in an adjoining chamber ; an icy coldness pervaded her body, and was soon followed by a violent agitation. Pains in the abdomen became very intense, and gra- dually disappeared without the irruption of the menses. The pains were doubly severe at the following period, from the 8th to the 12th of May, and subsided less completely than before. The menses did not re-ap- pear. The emaciation of her person, and the alteration in the colour of her features, the loss of her appetite, the impossibility of walking or standing, without inclin- ing very much forward, and frequent attacks of sick- ness of the stomach, induced her father to call in Dr. Godechaux. The patient endeavoured to conceal her DISEASES OF THE UTERUS. 33 situation as much as possible. The Doctor prescribed ten leeches to the thighs and laxative enemata, for which latter she substituted laxative pills and drinks, which the stomach rejected. Her situation becom- ing alarming, I was desired to see her in consulta- tion on the 31st of August; with some difficulty, I compromised with her modesty, and succeeded in placing my hand over the abdomen, and was soon convinced that the malady was to be found within it, I at first felt behind the pubes and in the hypogastric region a tumour, a little inclined towards the right iliac fossa, exhibiting by its position, form and volume, a tumour about as much developed as at three and a half months of pregnancy : it was very hard and sen- sitive ; the slightest degree of pressure upon it was painful. In the left iliac region, there was another oblong nipple-like tumour, dipping deeply into the pelvis. I first suspected the patient was pregnant, and her great reluctance in submitting to an examina- tion, seemed to confirm that suspicion. Finding it difficult to pass my finger into the vagina, I attempt- ed to ascertain the condition of the parts by an explo- ration through the rectum; this however, was so blocked up by hardened foeces, that a complete exami- nation was impossible. Her pulse was frequent and hard, skin dry and hot, mouth parched, tongue deep red. She was bled sixteen oz. from the arm : the sterco- ral matters were extracted from the rectum by a spoon handle. Being alarmed by our representation of her dangerous situation, she submitted to our pre- 34 A TREATISE ON THE scriptions readily. After having cleared the lower bowels of the mechanical obstruction, we administered an ounce of castor-oil, which gave her some colic- like pains, but Evacuated a large quantity of fcecal matter from the bowels. 1st September.—The abdomen yielding; the tumour in the left iliac region not now to be felt; that in the hypogastrium was not diminished; it had fallen under the median line of the abdomen and sunk into the pelvis. By the introduction of the finger into the anus, and applying the whole of the other hand upon the hypo- gastrium, I felt assured that the tumour was a deve- loped uterus. This could not be pregnancy, because the external parts were in such condition as to pre- vent ingress; it was not probably retained menses from occlusion of the os tineas, because she had already menstruated. I therefore concluded that this increase of volume of the uterus, was occasioned by an engorgement of its tissue, and consisted in an in- flammation, which though chronic at first, had become acute; this idea received some confirmation from the fact of the pain and great sensibility of the uterus under pressure. With this view, we had her bled twelve oz., and next day had twenty leeches applied to the hypogas- trium, which was kept constantly covered with emmolient cataplasms. She was also directed to use the bath and laxative drinks. I did not see her again until the 5th of September, when the tumour scarcely rose above the pubes, and she was free from fever or DISEASES OF THE UTERUS. 35 nausea. The pains had very much abated. Apply twelve leeches, continue the other remedies, allowing her skimmed milk and light broths, if she would relish them. 15th.—The tumour could scarcely be felt by pressing through the abdominal parieties towards the sacrum. In the evening she felt some pain in the lower part of the body, and during the night there was a slight ap- pearance of the menses. In a month from this time, she was able to be about without inconvenience. On the 10th of October, the catamenia returned with their usual freedom, and she has subsequently enjoyed good health. We may be astonished at the size to which the uterus may be increased in very young females, con- sidering the tenacity of its tissue at that time of life. There are, however, some instances in which the volume of this organ has been greatly augmented. See an interesting case of this kind reported by Dr. Sewall, in the New England Med. & Phys. Journal, August, 1815. CASE V. A young lady, aged about 20 years, enjoyed good health though her constitution was delicate. Her catamenia suddenly ceased, her abdomen and breasts enlarged, and she was supposed to be pregnant. She died 18 months after the cessation of her menses. At the opening of her body, the uterus was found filling up almost the entire abdominal cavity, adhering to the peritonaeum in many points, crowding the bowels gg A TREATISE ON THE towards the vertrebal column : its surface was irregu- lar, and the ovaries were confounded with the whole mass; its weight was 32i pounds. The natural cavity of the uterus contained several pounds of a dark coloured gummy fluid ; besides this, there was another sac filled with a sero-purulent fluid. When all these fluids were drained off, the tumour still weighed 22 pounds : its tissue was white, firm, inelastic and stud- ded with spots of cartilaginous and osseous degene- rations. Chronic engorgements of the uterus most frequently exhibit the character of congestion or in- flammation in women at puberty, who have not had sexual intercouse. Coition, although it is the natural excitant of the organ of generation, may by its abuse, or by its use in certain conditions of the female organs, occasion analogous engorgements, or con- tinue them when they already exist. These engorge- ments, the only appreciable phenomena of which are derangements of the menstrual function, are very frequent causes of sterility. We have seen women who attributed the misfor- tune of barrenness to the derangement of their cata- menia, become mothers after some months of com- plete abstinence of sexual intercourse, mild regimen and antiphlogistic means. If journeys either to waters or to places conse- crated to religion, have rendered some women pro- ductive who had hitherto been unfruitful, may we not, in many cases at least, ascribe these happy results, less to the use of the waters and the practice of devotion, than to the special repose in which the genital organs DISEASES OF THE UTERUS. 37 have been kept during this period : to the equilibrium which the change of air, scenery, freedom from care, &c. have established in all the functions of the sys- tem : to the diversions which these circumstances effected upon the abnormal concentration of vitality in the uterine apparatus, which having now resumed its natural organic relations, has recovered at the same time its healthy functions. When amenorrhcea or dysmenorrhoea depends upon engorgement of the uterus, a circumstance of more frequent occurrence than is generally believed, connu- bial intercourse, far from being useful in re-establish- ing the healthy functions of the uterus, increases the derangement; and by the excitement which it pro- duces, maintains the cause of it. Is it not also probable, that hysteria is sometimes the result of an altered condition of the uterus, and not owing to the coincident dysmenorrhoea, that, after marriage, this nervous condition is aggravated, in- stead of relieved 1 May it not be, that the failure of success in the treatment of some cases of disordered menstruation, usually considered as the primary disease, is attribu- table to our want of acquaintances with the causes of hysteria, or the derangements of the catamenia?— Indeed, the antispasmodic and stimulating emmena- gogues, mostly increase the congestion or inflamma- tion of the uterus, and consequently aggravate the consequences of that congestive or inflammatory state. The following case, amongst many others, the his- 33 A TREATISE ON THE tory of which 1 have collected, may illustrate my remarks. CASE VI. Sophia S., of a nervous temperament, had been crossed in her early inclinations, and subjected to unhappy dissentions in her family,—at the termina- tion of one of her quarrels, she experienced a sudden suspension of her catamenia. At the next period, she had an extremely slight discharge, attended with pain in the pelvis, and occasional paroxysms of hysteria— which afterwards recurred from the slightest causes. I was called to see her in a paroxysm of unusual severity and length. I learned that it was her men- strual period—that she was 17£ years old, and had menstruated since 15; and that the uterine function had been subject to derangement, seven or eight months. She was now perfectly senseless, without any other motion, than a kind of convulsion, occasion- ally. Her lips were colourless, her eyelids closed and quivering; the pupils were contracted, and the conjunctiva injected. I directed the application of 12 leeches to the vulva, and sinapisms to the feet. The paroxysm abated as the blood flowed. There were frequent attacks of hysteria after this period. The dysmenorrhoea continued, and a leu- corrhoeal discharge came on; at first periodically, but shortly after, was continual. I united with several other physicians, in the pro- DISEASES OF THE UTERUS. 39 priety of her becoming married to a young man of her choice, in 1818. She suffered much pain at the first conjugal em- brace ; and at the second, she had a paroxysm of hysteria—and from that time, the catamenia were interrupted. She had nausea and vomiting—and sup- posing herself pregnant, desired me to attend her during its progress, and at her accouchement. Her opinion was, that she was already advanced four months in that state, although there was a general emaciation of her person—and the breasts were flaccid or rather sunken, while the abdomen was very prominent. I passed my hand over the hypogastrium, and felt behind the pubes, a hard spheroidal tumour, pressure upon which caused pain, and a sense of weight in the sacral region. I was convinced by the touch, that this tumour was the uterus, though only as much developed as at two and a half or three months of gestation. Its neck was half an inch long, as large as a walnut, and very hard. I had her bled 12 oz. No change in her condi- tion having occurred during the following five days, I suspected an inflammation of the part, and repeated the bleeding, with prolonged immersion in a hip bath of tepid water—a mild regimen, and abstinence from sexual intercourse. The sickness of the stomach abated, and the pains in the pelvic region became less severe. There was a slight coloured discharge from the vulva ; and at the next period, the menses were as abundant as usual with her. She regained her appe- JO A TREATISE ON THE tite, strength, and embonpoint. She passed through the winter very well, and in the spring, during the absence of her husband, on account of business, she passed her time with an aunt in the neighborhood of Paris, where she lived exclusively on fresh vegeta- ble and milk diet. The hysteric fits were suspended, the menses flowed abundantly, and a little after the return of her husband in August, true pregnancy took place :—she however aborted at five and a half months. Ten months after this, she was again pregnant, though she aborted again within six months. Finally, after another conception, the ovum of which she parted with at three months, the uterus remained swelled, hard and painful. She was at this time, so much devoted in her attention to her husband, who was afflicted with phthisis pulmonahs, that she neglected herself. Becoming a widow, and continuing to suffer, she placed herself again under my care. I advised her to repose, to be bled every month, rub calomel ointment into the inner surface of the thighs, and observe a light regimen. In four months, her menses flowed easily and abundantly, and her health became re-esta- blished. Forced celibacy by depriving the genital organs of a necessary stimulant may throw the uterus into a state of inertia, which deprives it of the power of relieving itself by a sufficient discharge of the fluids which cause the menstrual movement, and thus con- gestions, and more or less slowly progressive engore- ments, follow. DISEASES OF THE UTERUS. 41 These engorgements which may be called colds, or catarrhs, in contradistinction to those which have been already spoken of, do not immediately exhibit any phenomena sufficiently prominent to reveal their existence, but at more advanced periods, they are followed by formidable consequences. Masturbation, on the contrary, by the repeated and permanent excitation which it awakens in the genera- tive organs, makes them a centre of determinations, and thus may cause chronic engorgements, manifested only by dysmenorrhaea, deprive the uterus of its capability of conception, and lay the foundation for the more tardy appearance of profound organic alter- ations. I shall remark, en passant, that commonly, though not always, chronic diseases of the uterus affect the body, or the whole of the organ in virgins—whilst they ordinarily have their seat at least primarily in the neck, with those who have indulged in sexual commerce, and particularly in those women who have conceived. Perhaps it is because in the former, uterine diseases result from indirect causes, whilst in the latter these maladies are produced by causes which operate directly upon the uterus, and mostly upon its neck only. It is easy to understand this after the exposition which has been made respecting these diseases, and from the manner in which they are produced. In addition to the excitement and the mechanical impression of coition, (contusion of the cervix uteri) it is occasionally the cause of other acute or chronic 6 42 A TREATISE ON THE affections of the uterus. I allude to the venereal virus, which, though it usually produces its effects upon the external parts of generation, it sometimes imme- diately attacks the neck of the uterus, and is the cause of various changes in its organic condition as engorge- ments, ulcerations and vegetations. The greatest number of the diseases of the genital organs, and particularly of the chronic diseases of the parenchyma of the uterus, originate in the consequen- ces of conception. The organization and vitality of this viscus are susceptible of new modifications. Its tissue becomes expanded and more permeable to the increased deter- mination of fluids into it; the exhalent orifices are developed to establish a more ample communication between the uterine vessels and that of the placenta; and lastly, the organ acquires the power of rapidly contracting itself. Although the separation of the parieties of the uterus for the development of the product of concep- tion, depends upon a sort of inherent expansibility, it is not always readily disposed to effect this extension, this indisposition, occasions in the course of the gestation, bearing down or dragging pain, and disagree- able tension, which are soon followed by abortion. Young ladies are most exposed to this accident, and we are assured that the greatest number of abortions or miscarriages occur in first pregnancies. It fre- quently happens that the first abortion is succeeded for a long time, or perpetually, by a difficulty in men- struation and a consecutive sterility. Numerous cases DISEASES OF THE UTERUS. 43 have proved to us that these functional disturbances result from a chronic inflammatory engorgement, of the uterus or of its neck only, which is susceptible of cure. Some cases of uterine cancer, not observed till after the cessation of the menses, have proved to us, that these diseases took their origin in a first and only abortion, after which the menstrual function had been disordered, and the women subjected to more or less severe, protracted and constant pains in the loins, &c.; all—symptoms denoting a morbid state of the uterus. Indulgence in copulation, and the neglect of hygienic and therapeutic precautions after abortion, doubtless contribute in no small degree, to maintain the chronic inflammation, occasioned both by the distention of the uterus beyond its intrinsic expansibility, and by the painful contractions brought on for the purpose of expelling the product of conception. Premature delivery, when it has been laborious, is a much more prolific cause of acute, though more frequently chronic affections of the uterus, than par- turition occurring at full time. The neck of the uterus first feels the effect of these lesions; it is also the part of the organ most apt to be affected in lying-in, in consequence of the pressure it sustains between the head of the infant and edge of the superior strait, the violent and forced distention in a too rapid labour, by imprudent manoeuvres, as the introduction of the hand for the purpose of turning the child, or the application of instruments, causing contusion and laceration of the sides of the orifice. 44 A TREATISE ON THE The violent application of the parieties of the uterus upon the body of the infant, when the contractions are very energetic, especially when the liquor amnii has been prematurely discharged, the irritation from turning the child in the cavity, the forcible extraction of the placenta, before its separation from the sides of the uterus; the manoeuvres of the hand in an attempt to detach and extract it, the mechanical and medical means employed to excite the contractions of the uterus when in a state of inertia, and to arrest hemorrhage, &c, are so many causes, capable of irritating the uterus, and exciting congestions, inflam- mations or engorgements, either in the whole, or a part of the body of this organ: these consequences, more readily arise from the persistence of the humoral and vital determinations which are necessary to the development of the product of conception. This con- gestive action bearing a strong resemblance to the menstrual molimen, may be much more easily dis- turbed by similar causes, whence analogous but more intense morbid effects result. In fact every thing capable of arresting the discharge of the lochia, with- out arresting the determination which furnishes the materials, becomes the cause of congestive or inflam- matory engorgement of the uterus. Such are the impressions of cold, the rigors of an intermittent,* and moral emotions of various characters. Even the most favourable accouchment, leaves the * See case 3d of this work, page 29. DISEASES OF THE UTERUS. 45 uterus in a state of engorgement, which is either dis- sipated by a determination of the fluids towards the mammse for the purposes of lactation, or else resolved in the course of the first nine days after delivery, though it may require a longer time if the uterus have been fatigued. If the woman rides, fatigues herself in any way, permits conjugal embraces, takes cold, or exposes herself to the excitement of any moral causes before the resolution of this congestion is com- pleted, it remains the nucleus of an engorgement which may gradually increase and sooner or later become the origin or focus of the most profound alterations. A circumstance of much importance and of which practitioners should not lose sight, is here presented. The uterus remaining engorged for a greater or less length of time after accouchment, necessarily acquires an excess of weight which tends to depress it towards the vulva and cause prolapsus uteri. This precipitation is favoured by the relaxa- tion of the vagina and ligaments of the uterus, as well as the yielding of the cellular tissue of the pelvis, in consequence of pregnancy and parturition. If we regard the displacement, merely, and apply a pessary, without previously removing the cause, the foreign body increases the irritation and occasions the development of profound alterations. We have very frequently seen this unfortunate mistake committed by physicians of great celebrity, become the source of serious consequences. (See case 57, &c.) In this condition of the uterus, the indication is to endeavour to effect resolution of the engorgement. (See cases 48—54.) 45 A TREATISE ON THE My opinion as to the secondary part which the relaxation of the ligaments plays in the production of prolapsus uteri, and that it arises much more from increase of weight in the organ, in consequence of engorgement of whatever nature, is confirmed by the following circumstances: 1st. The greatest number of engorgements of the uterus, tend ultimately to produce its descent in the vagina, and even its escape from the vulva. 2nd. This displacement occurs in women who are afflicted with engorgements of the uterus, even though they have never conceived. 3d. In cases of the co-existence of descent with an en- gorgement, the resolution of the latter, effects the dis- appearance of the former. From amongst a number of examples of prolapsus, in consequence of engorgement of the uterus in wo- men who had never been impregnated, I select the following : CASE VII. Miss C----, of a nervous temperament, and cross- ed in her early affections, experienced all the symp- toms indicating a congestive engorgement of the uterus. She became married, and suffered intolerable pains from sexual intercourse; she even had severe hysteric fits from it. After a superficial examination of her case, all her sufferings were ascribed to a pro- lapse of the uterus, which was found just within the vulva. Spunges were introduced to keep it in its place: they however, gave her so much uneasiness that she DISEASES OF THE UTERUS. 47 could not wear them. Repose, blood-letting, and a mild regimen, caused both the engorgement and pro- lapsus to disappear, although the hysteralgia con- tinued, being maintained by the nervous susceptibility of the patient, and by numerous irritating circum- stances by which she was surrounded. It has been an opinion, in which even some accoucheurs have indulged, that pregnancy effectually cures prolapsus of the uterus. It must be evident, however, that whilst the disease is occasioned by engorgement, coition will be injurious, and pregnancy impossible. The opinion advanced, has not been based upon sufficient observation, and is therefore worthy only of the " old women.'''' In proportion, as the woman advances in age, and passes the period which nature has assigned to the reproductive life, the tissue of the uterus is disposed to relapse into a state analagous to that which is pre- sented before puberty : contracting and becoming less and less permeable, at the same time the menstrual movement, which had formed in this organ a centre of vital activity and sanguineous determination, de- creases daily and is completely suspended in most cases by the 40th, or from that to the 46th year. Unhappily, this physiological march, is not uniform in all women; in some, this sanguine determination continues without measure as well as without periodi- city : consequently, if the uterine parenchyma has lost its integrity, it permits the blood to escape in proportion as it flows into the vessels, or after its tissue has been engorged by it. This is an abundant Ig A TREATISE ON THE source of hemorrhages, either without, though general- ly with engorgements of the uterus, by the profuseness or frequent repetition of which the woman is placed in imminent danger. If on the contrary, the vital actions of tlie uterus are increased by a more mode- rate determination, the result will be chronic inflam- mation, with induration or exhuberances, as polypus or other vegetations. It is moreover, chiefly at this period of life, that, in consequence of a peculiar modification in the organi- zation, there are developed in the uterus, abnormal substances, tissues unlike any other in the economy, constituting scirrhus, cerebreform, melanic and other affections, the subsequent alterations of which mostly give place to cancerous diseases. The occurrence of these circumstances at this period, has given it the name of critical age. It is improper that we should indiscriminately ascribe to the critical age, all the diseases which are manifested at this time. It should be borne in mind, that a great many of the alterations considered as resulting from the cessation of the catamenia, have originated at an anterior period; the " turn of life," merely developes these affections, changes their cha- racter, or accelerates the successive transformations of which they are susceptible. In a very exact history taken from 40 women, between the ages of 40 and 50 years, who were affect- ed with cancer of the uterus, only five were found in which the disease was of recent origin, or had resulted from the critical period; in 33 others, the catamenia DISEASES OF THE UTERUS. 4 stipation. Bleed in the morning; give three grains of calomel in three doses; apply 40 leeches upon the right side of the abdomen. 5th day.—Fever moderated; abdomen bloated ; constipation. Leeches; pills of calomel, and extract of belladonna, each a grain, every two hours. Increase of bloating of the abdomen, with agitation. Bath for half an hour. For the first time, the patient dis- charged flatus from the bowels. 6th day.—Slight sensibility in the iliac regions. Leeches; bath. The patient had one alvine evacua- tion. 7th day.—The posterior part of the bladder adher- ed to the rectum ; it was separated by the finger, and 440 A TREATISE ON THE there was discharged an ounce of brown fetid fluid. Enemata; 20 leeches upon the side ; broths ; injections of tepid water into the vagina, to wash away a sort of fetid exhalation, which escaped from it by compres- sion. 10th day.—The ligatures were withdrawn. 14th day.—She continued to improve, and on the 27th day—It was found that the bottom of the vagina, formed a pliant ring which would scarcely admit the finger—it communicating with the cul-de- sac, of the depth of two-thirds the first phalanx of the index finger, formed by the re-union of the bladder and rectum. Professor Roux has practiced the extirpation of the uterus twice, and in both cases the patients died : one nine days, the other 24 hours after the operation. In the first, he could not avoid cutting the posterior face of the bladder, which adhered to an enormous tumour, and might be taken for the body of the organ itself. The division of the bladder could no better be avoided by Dr. Blundell, in one of the four cases which he ope- rated upon. The patient died a few hours after the extirpation, as did also two others operated upon. M. Langenbeck lost in 24 hours, the patient which he had operated upon after the manner of Gubertat. He operated upon two others by Sauter's process: one perished the 2d day, and the other the 14 th. Paletta and Mateggia, extirpated a uterus which they took for polypus; the patient died in less than two days. Finally, two patients operated upon by M. M. Siebold and Holocher, perished in less than nine hours, which DISEASES OF THE UTERUS. 44 J makes of fourteen cases of extirpation, two of com- plete and one of incomplete success. The one opera- ted on by Sauter having died accidentally, in conse- quence of indigestion four months after the operation. Haemorrhage is the least accident to be dreaded, in consequenee of extirpation of the uterus. Drs. Blun- dell and Sauter, neglected to apply ligatures, yet the loss of blood was very moderate. The plan of Reca- mier, removes all fear on that score. But the shock communicated to the nervous system by the manoeuvres and the length of the operation, which to be well performed, has often taken half an hour and sometimes an hour; the inflammation almost inevitably resulting from the incisions, tractions, bruisings, the penetration of the air into the cavity of the peritonaeum, an inflammation which it is not always possible to conquer, renders the consequences of this operation promptly fatal. I here speak of those cases only in which the organs in the vicinity of the uterus, have not been involved during the operation. If to those serious inconveniences, are added those which result from the danger of relapse, excited either because some altered point of the appendages of the uterus may have escaped the investigation of the operator, or because some organic or vital modifica- tion which has presided over the first development of the original cancer, recalls it in the cicatrix, or the parts more or less remote, one would be authorised to in- quire, whether it would not be most advantageous to humanity and to science itself, to abandon a rash 56 442 A TREATISE ON THE operation, which, for the very small amount of suc- cess, presents so many perilous chances ? What is proposed in the majority of these opera- tions ? Is it to save the life of the patients, and pro- long their existence 1 Three cases operated on for the extirpation of the uterus, have obtained an indif- ferent cure, and consequently a prolongation of their existence. In the eleven others, operated on, death has occurred much more promptly, than if it had been the result of the disease abandoned to itself. Besides, is art impotent to calm and render tole- rable those symptoms which make cancer of the uterus, so cruel an affection ? If in some extreme cases, the palliative treatment is without marked advantage, in the greater number, much benefit is derived from it. By it the existence of the patients is prolonged, and the rest of their lives rendered supportable. Every thing depends upon hygienic and medical means being well chosen, combined and directed according to circumstances. I hope I have sufficiently indicated the path which the practitioner is to follow in this respect, in speaking of the treatment proper to each species of confirmed cancer. " It must be very evident, that extirpation of the " uterus is one of the most painful and most severe " operations in surgery, because it is most frequently " mortal. It should be undertaken only with great " caution; and it should never be, unless it is very " probable that the disease has not passed the limits " of the uterus, but that this organ preserves all its DISEASES OF THE UTERUS. 443 " mobility, with regard to the neighbouring parts. " The signs of this limitation of the disease, and of " this mobility, are acquired by all the means for the " exploration of the uterus; and unhappily, these " means are very treacherous. Two very skilful " men,* have misapprehended the extension of the " disease to the tubes and ovaries, which are so " frequently involved, when the body of the uterus is " affected. It must be concluded from this, that it " would mostly be very wise, to abstain altogether " from the operation."t GENERAL CONCLUSIONS. 1st.—Most of the confirmed cancer of the uterus, succeed to engorgements and ulcerations, susceptible of cure. We may then, to a certain extent, prevent the development of these diseases, by treating proper- ly from time to time, the primitive pathological states of which they are most frequently only the fatal con- sequence. 2ndly.—Once developed, confirmed cancers are even now, beyond all the resources of medicine; sur- gical treatment itself, which offers some favourable chances when the disease is limited to the neck of the uterus, becomes inefficacious when it affects all or a part of the body of this organ. * Sauter and Roux. t Gendrin. 444 DISEASES OF THE UTERUS, &c. 3rdly.—In all these cases a palliative and well- directed symptomatic treatment may retard the pro- gress of the disease, render it in some degree station- ary, remove or destroy the most painful symptoms, and the most serious inconveniences, or at least mollify them so as to render the approaches of inevitable death less painful. 4thly.—All the cases of the extirpation of the uterus, published, have been reported at a period too shortly after their execution, (four, five, and six months at most,) to enable us to judge of the results of such an operation. It is very probable that if they are longer deferred, the confirmation of definite success would have been still more rare. INDEX. PREFACE. Introductory Observations, ix Question proposed by the Medical Society of Bordeaux, x Division of the work, . . . . xii Extract from a report made by a committee on behalf of that Society. ...... xiii PART I. CHAPTER I. Origin and causes of the organic affections of the uterus, 21 Examination of the mode of production of these affections, 22 First, in Virgins, ... 23 Case First, . . . .24 Case Second, ... 27 Case Third, . . .29 Case Fourth, ... 32 Case Fifth, . . .35 Second, in women and girls who have cohabited, but who have not conceived . . 36 Case Sixth, . . .38 The different seats which the alterations of the uterus affect, before or after conception, . . 41 Third, after conception, . . 42 Effects of gestation, . . .42 abortion, . • 42 accouchment at full term, . 44 Causes of the descent of the uterus, . 46 446 INDEX. Case Seventh, . . .46 Fourth, at the critical period, . . 48 Should we attribute to the influence of this period all the diseases of the uterus which are observed at that time ? 48 Case Eighth, • • . 49 Case Ninth, , . 49 Fifth, in aged women, . , 59 Case Tenth, . . 52 Case Eleventh, • • . 53 CHAPTER II. Mode of formation, development, and termination of the alte- rations of the uterus. . . 5= Theory of the scirrhous alterations,