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A REVIEW

OF THE

PRESENT STATE OF UTERINE PATHOLOGY.

CHAPTER I.

PRELIMINARY REMARKS.

THE PATHOLOGY OF THE UTERINE MUCOUS MEMBRANE FORMERLY IGNORED, NOW DEFINITIVELY ELUCIDATED.

UNFORTUNATELY for the medical community, and still more so for the numerous females suffering from uterine symptoms whom its members are called upon to treat, the greatest diversity of views respecting uterine disease still obtains amongst those who are looked up to as authorities. Not only is this the case in England, but also in France, where uterine pathology has occupied so much of the attention of the profession during the last twenty years; as is proved by the late discussion at the Paris Academy of Medicine. That my writings have contributed to this diversity of opinion, both at home and abroad, is more than probable, and I can only hope and trust that they have, even in so doing, exercised a beneficial influence, by directing the current of professional research in a sound and true direction.

It is now more than ten years since I first made known, in The Lancet, the opinions and doctrines I entertain with reference to uterine diseases. These doctrines have been favourably received, adopted, and acted upon by very many practitioners in nearly all parts of the world, and I now feel that it has become a duty incumbent upon me to state what influence or change, time, additional experience, and the labours of those who have followed me in the field of scientific investigation, have produced in my mind. I feel the more called upon so to do, as I have been for many years a silent, although certainly not an indifferent, observer of all that has been written and said in favour

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of or in opposition to the views I advocate. I have endeavoured to learn from my opponents the weak points of my own doctrines. I have tried to think that they might be right and that I might be wrong, and year after year have repeated my observations on large masses of sufferers. I have tried to divest myself of all prejudice or preconceived opinions, and endeavoured to arrive at conclusions, as if all were doubt and obscurity in my mind; as was the case before I had accomplished the unravelling of the confused web of uterine pathology, such as I found it in my earlier days.

All these experimental researches and investigations have, however, invariably led me to the same results-to the confirmation of the doctrines brought forward in my papers published in The Lancet in 1844-45, and in the successive editions of my work on Uterine Inflammation. Had I not already arrived at these doctrines, the observation of any one year might have led me to the erection of the scientific edifice which the work alluded to contains. How could it be otherwise when all the cases I meet with, in their previous history, in their progress, and in their results, corroborate them? May I also be allowed to add, incidentally, that I have constantly been receiving corroborative testimony from men practising in the most distant parts of the globe, whose intellect, powers of observation, and sincerity, I cannot but respect, and who appear to have studied the question conscientiously, and without any other bias than the one, decidedly inimical to my opinions, of former professional convictions.

The views I have propounded may be said to be the result of the progressive improvement of medical science, which has been taking place since the close of the last century. They flow naturally, inevitably, from the direction which pathologists since that epoch have given to medical investigations. From the moment that theories, that preconceived general views, were more or less laid aside, and that Nature herself was questioned -from the moment that pathologists began minutely to examine the changes that occur in our organs during life, or are found after death-all the discoveries which my predecessors and I have made with reference to the uterus became inevitable, and merely a question of time. It was impossible that every organ

in the economy, however minute, however physiologically obscure, should be examined, probed, analysed, in health and disease, and that the uterus alone should escape investigation. I and those who preceded me have merely endeavoured to accomplish for the uterus what the crowd of modern investigators have done or are doing for other organs. We are men of our time, contributing to the scientific structure which is now rising by degrees on a basis unknown to the votaries of science in the darker ages of the human intellect, that of faithful, conscientious observation, and careful, accurate induction.

Medical men of all ages have observed an intimate connexion between the train of symptoms to which the generic term "uterine" is given, and morbid conditions of innervation, digestion, and nutrition. The connexion, however, which so constantly exists between these general morbid states and chronic inflammatory conditions of the neck and body of the uterus was universally ignored until the beginning of the present century, when it was rediscovered by M. Récamier, the late distinguished physician of the Hôtel Dieu at Paris. I say rediscovered, because, as I have elsewhere proved, traces of a knowledge of these local morbid uterine states are to be found in the writings of the Greek and Roman physicians of antiquity. M. Récamier, and subsequently M. Lisfranc, who laboured actively in this new direction, whilst endeavouring to connect general symptoms with local disease, merely followed in the wake of the pathologico-physiological or Broussaian school, in the palmy days of which they lived and flourished. Their labours are certainly amongst the most valuable that we owe to this school, which, during the early part of this century, contributed so much to our positive knowledge of disease and of the anatomical changes which it produces during life in the human economy. Previous to these eminent men, the knowledge of uterine pathology, as it existed in the Paris school, was limited to a more or less perfect acquaintance with fibrous tumours, polypi, cancer, acute and chronic metritis, and displacements. Functional derangements, such as amenorrhoea, dysmenorrhoea, menorrhagia, sterility, abortions, &c., were attributed to vital uterine states, to irritability, or to want of tone of the uterus,

or to the debility and disordered state of general health, which so frequently accompanies these functional derangements. The leucorrhoeal discharges, which are also so frequently observed along with these conditions, were considered to be merely symptomatic in the great majority of cases. Such, I may safely say, was also the view taken of uterine pathology in our most esteemed works on the subject up to the time when my first contributions to uterine pathology appeared. Moreover, such

are still the views of a large portion of the medical profession in this country at the present time.

In uterine pathology, thus viewed, there are many errors, many oversights, but there is one especially which not only weakens, but totally destroys it-the pathology of the uterine mucous membrane is ignored, is passed over all but as if it did not exist; although the mucous membrane which lines the two cavities of the neck and body of the uterus is a most highly organized and a most important one. Its liability to inflammation and to inflammatory lesions, and the influence which such inflammation exercises over all other morbid uterine conditions, with the exception of cancer, is so great as to render an intimate knowledge of its diseases absolutely indispensable for the understanding and successful treatment of uterine affections, and of disordered functional uterine conditions. Nor is it surprising that such should be the case. If we go back to general pathology, if we refer to the laws which regulate disease in each of the separate tissues which, by their combination, constitute the animal economy, we shall find that wherever there is a highly organized mucous membrane, the inflammatory lesions, acute or chronic, to which that mucous membrane is liable, constitute the principal feature in the pathology of the organ to which it belongs. Morbid growths, cancerous degenerescence, and mere functional derangements, are everywhere infinitely more rare than these mucous membrane lesions. Thus, in the lung, how infinitely more frequent are bronchitis and the emphysematous or asthmatic conditions which it often entails, than pneumonia or pleurisy—that is, than inflammation of the substance and of the serous covering of the lungs ;-or than morbid growths, or cancerous degene

rescence; or than mere functional derangement. The same may be said of the throat, of the eye, of the intestines, &c. In each organ, the mucous membrane has its own individual peculiarities and liabilities, depending on structure, on functions, and on physiological exposure to offending causes, but still the general law is the same in all, as regards the comparative frequency of its diseases.

We might also, à priori, conclude that this particular mucous membrane would be more than usually liable to inflammation, and to inflammatory ulceration, and that these morbid conditions, once established, would be more than usually difficult to remove, when we reflect that it presents important structural and physiological predisposing conditions. Thus it contains, scattered throughout its texture, a vast number of mucous follicles, and these follicles, in all mucous membranes, are very liable to take on inflammatory action, and, as a sequela, to ulcerate. The physiological predisposing causes of inflammation, also, are numerous; the principal one being the menstrual congestion to which the uterus is periodically exposed for about one week in four during the entire duration of uterine life.

And such, in reality, modern research has proved to be the case, by the employment of physical or instrumental means of investigation. Inflammatory lesions of the uterine mucous membrane are as frequent, indeed, even more frequent, than the laws of general pathology would have led us to expect. Moreover, they are perhaps more liable to pass into the chronic stage, and more difficult to eradicate than in any other mucous

membrane.

What general pathology, however, could not discover, although it might foreshadow it-what could only be brought to light and proved by experience-is, that permanent functional derangements of the uterine system, and the general conditions of dyspepsia, debility, and morbid cerebro-spinal innervation, which generally accompany such functional derangements, are mostly occasioned by these mucous membrane lesions and their sequelæ, and are only to be permanently got rid of by their entire removal.

This is one of the most important lights that modern science

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