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CHAPTER V.

THE DISPLACEMENT THEORY.

HISTORICAL CONSIDERATIONS.

By the expression, Displacement Theory, I refer to the opinion held by those practitioners who consider that the displacements of the uterus so frequently recognised in females presenting symptoms of uterine disturbance and suffering, are the principal and often the sole cause of these conditions. The questions raised by the consideration of these opinions are by far the most difficult to solve of all that I have had to examine in the course of this review, and have now for many years exercised the minds of the most eminent uterine pathologists, both in this country and in France. In the latter country, the pathological importance and the treatment of uterine displacements was discussed for three consecutive months, during the year 1854, at the Academie de Médecine, and most of the more eminent Paris uterine pathologists took a part in the debate. It would indeed be vanity for me to pretend to accomplish what they failed to do, to clear up the obscurity which surrounds this vexata questio, entirely to solve its difficulties, and such a pretension is far from me. Without aspiring, however, to so much, I hope to be able, by appealing this time to my own personal experience, to contribute to the defence of the doctrines which observation has led me to adopt, from the vigorous attacks which they have had to sustain.

The existence of uterine displacements, other than prolapsus, has long been noticed by writers on the Diseases of Females, but the attention of the profession does not appear to have been

more than casually directed to them, until Récamier, by his minute researches into uterine pathology, roused a new spirit of inquiry amongst his countrymen. It would appear, from the recent discussion at the Paris Academy, that as far back as 1826, thirty years ago, M. Amussat, impelled to investigation by M. Récamier's example, recognised the clinical fact, that falling or prolapsus of the uterus is not the only displacement to which that organ is liable; and that displacements, forwards and backwards, anteversion and retroversion, are also very common. M. Amus

sat made in that year many attempts to replace the uterus, and to keep it replaced by mechanical means. He states that he invented and tried various kinds both of extra-uterine and of intra-uterine sounds, and pessaries, specimens of which he presented to the Academy at the late debate. His researches in the direction of intra-uterine support were arrested, however, by the death of a young lady, suffering from anteversion, into whose uterus he had introduced an ivory stem pessary, with the view of permanently straightening it. She went home, was attacked with inflammation, and died "promptly."

Discouraged by this sad event, M. Amussat ceased to make any efforts to straighten the uterus by mechanical agents applied to the interior of the organ, and directed his attention merely to cervical and vaginal means of treatment and support.

A few years later, M. Velpeau commenced a series of experiments with the same view, that of straightening the womb mechanically, through the agency of intra-uterine sounds. He invented a metallic spring stem, which he first introduced curved into the uterus through a gum-elastic canula, and then straightened by touching the spring. Finding, however, that although the intra-uterine sound temporarily restored the uterus to its natural direction, its presence occasioned severe accidents, M. Velpeau likewise discarded its use, and, from that time forward, principally relied on bandages of various kind, and especially on abdominal bandages.

My own personal knowledge of Parisian uterine opinions and practice dates from the year 1836, in the early part of which I joined the medical schools of that city. During nearly eight years that I remained there, I was, without interruption, con

nected with the hospitals as pupil, dresser, clinical clerk, housesurgeon, or house-physician, and thus became acquainted with the views and practice of most of the surgeons and accoucheurs who have taken part in the recent debate; for it is worthy of passing remark, that surgeons and accoucheurs only spoke on the subject under discussion, not a single physician having joined in it. I was from the first thrown in contact with M. Velpeau, to see whom I had visited Paris, and who then and since has ever shown himself to me the kindest of teachers and friends. I can thus bear testimony to the fact, that he was at that epoch constantly lecturing on anteversion and retroversion. Indeed, during the year 1838, when I officiated under him at La Charité, as dresser and clinical clerk, I took down many cases of this description, in his female wards. At that time, he was not using for treatment any mechanical means of support, but depending on rest, general treatment, and the use of bandages. The speculum was also but seldom resorted to, and inflammatory lesions were but little talked of. He was clearly then, even more than now, under the influence of the mechanical views of uterine pathology—that is, he then attributed, as he still does, principal importance to displacements of the uterus. He thought that they often existed independently of inflammatory action, as a cause, and considered them to be the main origin of the uterine suffering which so often accompanies them.

I was the more struck with these views, as at the same time I had become acquainted with the doctrines and practice of Lisfranc and Gendrin at La Pitié. These practitioners both used the speculum constantly, considered the lesions which it brought to light as of primary importance, and the displacements-deviations they are called in Paris-which accompany them, as secondary phenomena; generally speaking, the result of inflammatory engorgement or enlargement.

Since then, in Paris, uterine pathology has obeyed these two directions. Some have followed Amussat and Velpeau, and inclined to what I have called the "displacement theory"that is, to the interpretation of uterine suffering by uterine displacement; whilst others, on the contrary, following Récamier, Lisfranc, and Gendrin, have inclined to the inflammation

theory. I need not tell my readers that I myself belong completely to this latter school. The more I have studied and observed, the more convinced have I become that the true key to by far the largest part of the field of uterine pathology is to be found in the accurate knowledge of inflammation in the different tissues and regions of the uterus.

Although uterine pathologists have been thus, in Paris, separated, as it were, theoretically, into two schools, I may say that the actual treatment of uterine disease has not so essentially differed as might have been expected until the recent researches and publications of our countryman, Dr. Simpson, became known. All, or nearly all, admitted the frequent existence of inflammatory lesions, and taught that they ought, once recognised, to be treated and removed. Only, those who considered these lesions the "fons et origo mali" were satisfied that they had done all that was necessary for the local treatment of their patients when they had removed them; whereas those who thought the displacements of the uterus the principal mischief, and the inflammatory lesions mere epiphenomena, often overlooked their presence, and trusted from the first to pessaries, bandages, &c.

In the late discussion at the Academy of Medicine, these two schools were very fairly reproduced. Singularly enough, the surgeons, represented by Velpeau, Amussat, Malgaigne, Huguier, &c., principally took the displacement view of the subject. Whereas the inflammation view was supported by the physician-accoucheurs, Paul Dubois, Depaul, and Cazeau. This fact, which struck me at once on reading the report of the discussion, renders it all the more difficult for an impartial observer to judge between conflicting opinions, as it shows the existence of a mental bias, corresponding with the general tenour of studies and of professional preoccupation. Is it not possible, however, that practitioners, whose pursuits, like those of accoucheurs, are not purely either medical or surgical, and whose position in the healing art is, consequently, a double one, may be the best qualified to judge a question which evidently lies on the frontier-ground between medicine and surgery ?

In Great Britain, displacements of the uterus, with the ex

ception of prolapsus, were but little thought of until the publication of Dr. Simpson's paper on the Uterine Sound, in 1843, and more especially that of his essay on Retroversion of the Unimpregnated Uterus, in the Dublin Quarterly Journal for May, 1848. In this latter able and lucid memoir, Dr. Simpson described at length retroflexion and retroversion of the uterus. Finding the replacement of the retroverted uterus by means of the uterine sound totally inefficient, he proposed for their treatment his fixed stem pessary. This pessary comprises, as every one knows, three parts; the stem two inches and one-third long, which occupies the cervical canal, and enters the uterus, terminating in a bulb on which the cervix rests; and the vaginal and external parts, by means of which it is fixed on the pubis. It thus mechanically straightens the uterus, and maintains it all but immovable. In his essay, Dr. Simpson merely alludes to anteversion, on which French pathologists lay great stress, and he does not speak of lateral displacements, or latero-versions. He enters, however, at length into the pathology of retroversion, and ascribes to it most of the symptoms of uterine disturbance and suffering which I and others ascribe to inflammatory lesions. The intra-uterine mode of treatment is also brought forward by Dr. Simpson, in the essay in question, as one which he had tried for some time, found free from risk or danger, and pre-eminently successful.

The intra-uterine, or stem pessary, thus revived,—simplified and improved no doubt, and guaranteed as a safe and efficacious agent by a pathologist of great weight and authority,was received with favour, both in this country and abroad, by the followers of the mechanical or displacement school. To them, the deviations of the uterus were still the principal cause of uterine suffering, and yet they were miserably deficient in means of treatment. M. Amussat was reduced to propose to establish adhesion between the posterior surface of the cervix uteri and the vagina by means of potassa fusa! M. Velpeau seemed to rely on abdominal and other bandages; M. Hervey de Chegoin and others, on vaginal pessaries of various forms and materials and all to little or no purpose, for the displacements were obstinate, and the womb would not be replaced or

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