Annual Oration 1833
By Walter Channing, M.D., M.M.S.
I have chosen for the subject of this discourse Irritable Uterus. It has for the first time been quite recently described. This fact of its comparative novelty may give to it some interest. But it has others. The disease is a very painful one; of great obstinacy even under very careful and appropriate treatment, and is liable to recurrences as well as exacerbations from causes which the most prudent cannot always escape. It has local symptoms sufficiently distinctive; yet it is very likely to be confounded with many other, and better known affections of the womb. Mistakes in diagnosis therefore must have been hitherto very common, and must frequently have led to opinions as to the chances of recovery very painful to the patient, while at the same time she was subjected to treatment, much of which could only have added to her discomfort and misery.
Still these patients did get well in the great majority of instances; but while the prognosis was thus falsified by the event, the patient was the principal gainer. The profession has found little added, at least to its active means, in the management of a painful and protracted disease, for recovery often takes place when the least efficient are employed; nay, when the disease and the patient are left quite to themselves.
I have referred to local uterine symptoms. But there are others which appear in parts very remote from the uterine system. These imitate in their variety all sorts of maladies; and by their persistency, apparently afford sufficient reason for the pathological views which have been taken of them. Here again erroneous diagnosis has led to evil. This remark is supported by what may be found in books on the diseases of women in all periods of medical history. Its illustration is at hand in the latest, our own, in much that has been written on mimotic diseases, so called; and also in certain views concerning a pathological state of the spine, which have been so strongly urged by those who first advanced them, and which have found here as well as abroad strenuous advocates.
The name given to this disease is Irritable Uterus, and the affections with which is frequently found accompanied, have been designated “Disorders of Females, connected with Uterine Irritation.” These terms are used to express a state or condition of the womb, on which some peculiar morbid manifestations depend; and it is perhaps not easy, or very important for a name to do more. An exalted sensibility, rendering pressure on the part affected in some cases insupportable, and in all painful;—pain more or less severe at all times, and thus independent of pressure,—these, with certain functional derangements, and various sympathetic affections, are among the elements of this disease. In farther treating my subject, I shall first describe irritable womb: giving its history under the heads of subjects, causes and symptoms,—secondly, offer some explanation of the cause or connexion of its facts, with a view to its theory,—thirdly, give the diagnosis, perhaps the most important inquiry involved in the discussion; and, lastly, the treatment.
And first, of the History. Irritable womb appears in two very different classes of patients, and it would be very useful in the management of each case, could we ascertain beforehand to which class it belongs. The first class embraces all those cases in which the general health has long been impaired, but in which we have not been able to discover any paramount local derangement. This state of general feeble health may continue a long time, and at some remote period, local irritation, of the womb it may be, or of the spine, or other part,—of the first most frequently,—will show itself, and we may have presented, and very suddenly too, its special local symptoms, and at no distant period, its sympathetic affections. The womb, it was said, most readily betrays irritation, and because its healthful functions are very readily disturbed, and from slight causes, in this class of cases, and such disturbance alone may at once become the exciting cause of our disease. A new aspect is now given to the case. The negative symptoms, if I may use the term, assume a positive character; the disease acquires a local habitation, and a name, and preserves both with an obstinacy which a gradually accumulating predisposition almost always ensures.
The second class embraces all those cases in which little or no derangement of the general health has been before noticed; but in which a marked, and it may have been, accidental, derangement of the uterine functions has been experienced. Here uterine irritation is the first morbid phenomenon in the series, the more general affections being wholly consecutive. The disordered state of the womb then, which is followed by irritation, may be strictly idiopathic; at least we may fail to trace it to any general or local cause.
Uterine irritation rarely occurs before twenty, though it has been observed as early as the eighteenth year. It requires for the most part, for its perfect development, a state of the womb which is rarely produced by a short or temporary continuance of disturbing causes. Months and even years may elapse under the operation of such causes, before the organic predisposition has been brought about. There is much however in the previous condition of the individual which deserves notice. From the establishment of menstruation, there may have existed marks of bad uterine health. The disturbances which attended its beginning, may have characterised its subsequent periods, and gradually that state be produced on which we have supposed the whole manifestations of irritable uterus to depend. Irritable womb then, if not strictly a disease of the young, may be in a forming state from the beginning of puberty. The symptoms of this state are excess or deficiency in the quantity of the catamenia at each natural period, and a too frequent or too rare recurrence of the menstrual function, with an unusual sensibility of the pelvic viscera, and more or less marked general derangement; this last appearing under the various forms of an accelerated and easily excited pulse,—variable temperature,—more or less derangement of the chylopoietic viscera,—and lastly, much susceptibility of moral impressions. The careful investigation of all these facts is of exceeding importance. Their management will do much to prevent or to accelerate the invasion of irritation; and one modification of it, viz. that in which irritation is not yet excessive, may be present for some time without being recognised, and may be much exasperated by the use of means addressed to some one of its occasional symptoms.
A predisposition to irritable womb, may be looked for in that condition of the organ which induces dysmenorrhœa, and menorrhagia, and it has in fact been considered to be a protracted form of the first named disease. But painful menstruation may and does exist independently of uterine irritation, and the occurrence of the former along with the latter, when fully formed, is so common, but at the same time so easily accounted for, that we are not to be surprised that the order of occurrence of the two events has not always been accurately traced. I speak of dysmenorrhœa here, not precisely in the technical use of the term; I only mean to express by it, the fact that menstruation is painful. I have, I may add in passing, seen it in its true character, the discharge consisting principally of a semi-organised membranous texture, in a case of exquisite uterine irritation. Predisposition, farther, may be produced by frequent abortions, especially when they rapidly succeed each other. Susceptibility of impregnation, it has been asserted, does not exist when the disease is fully formed. I cannot but think, however, that I have met with striking exceptions to the rule, if the wider observation of others have established one.
The exciting causes are such as directly or remotely act upon the womb. Among those which may be named as belonging to the first, are astringent and cold injections into the vagina, either to suppress or check excessive lochia, or menorrhagia. Another is the pessary. I have known a very obstinate form of the disease to follow the use of a pessary, introduced to obviate great uneasiness in the pelvis, accompanied by slight displacement of the womb. It has also followed the long continued use of the same instrument, which has been allowed to remain, and becoming foul from neglect, has produced the disease. Other causes are, various forms of over-exertion, as fatiguing exercise, or long-continued standing, either too soon after premature confinement, or during the catamenial period. No existing cause is so distinctly recognized by all who have paid most attention to irritable womb, as this single one of excessive bodily exertion. What is quite worthy of remark here, is that a disease, which a single act of imprudence may excite, and from which we might look for recovery in temporary rest, will, from the moment it begins, go on with scarce any interruption, and produce years of misery. This teaches how near is the state of predisposition to the fullest development of the malady. The precise agency of exercise in producing it is not easily explained. It certainly is not by inducing prolapsus, for though they frequently exist together, at least some slight displacement, true prolapsus, I believe, is not an essential element of the disease.
Of the Symptoms. These have regard to the womb and its neighbourhood, and to the system generally. Of the first is pain in the lower part of the abdomen, referred to the brim of the pelvis, most severe just above the symphysis pubis, and always increased by pressure. The course of this pain will be very distinctly pointed out by the patient, and her account will be abundantly verified by passing the hand or finger in the direction thus indicated. Other neighbouring parts are seats of pain, as the loins, the sacrum, and the thighs. Bearing down, at times, accompanies these last, especially during the menstrual periods.—These symptoms are aggravated by exercise, and by the erect posture, and the patient now finds added to them lancinating pains through the pelvis, shooting from the neighbourhood of the symphysis on the inside, to the opposite point in the hollow of the sacrum. The operation of an active cathartic, especially such as excites the large intestines, and their lower portions, are attended and followed by a similar aggravation of symptoms. Such cathartics increase the ordinary motion which attends dejections, and in this way act as other exertion may.
It is in the womb itself we discover the symptoms which are most distinctive, and one of which has led to the name which the disease bears. The finger being introduced into the vagina, and applied to the neck of the womb, finds this last in the great majority of cases exquisitely tender, barely tolerating the slightest pressure; the pressure often exciting paroxysms of intense suffering, which may continue some time after their exciting cause is removed. I have described the state of the neck, in the perfectly developed disease. Different degrees of the same are noticed in various cases. In those of the longest standing, and in which the symptoms in other organs, or parts of the body, have acquired the ascendancy, the uterine irritability may be much diminished, and in some is so slight that the patient suffers comparatively little during examination. I refer to this fact here because in the management of such a case, the state of the womb may be the true cause of the continuance of the symptoms referred to, while its own morbid sensibility is so much diminished as not to be duly estimated in our investigation of causes. This tenderness in many cases, and by the observation of some writers, is in all confined to the neck of the womb. I have attended to this statement very particularly when examining patients, and have been led to think that it is not so universally true as has been asserted. Thus, on examination by the rectum, by which the body of the womb may be felt; and per vaginam, by carrying the finger to, and around the cul de sac, formed by the connexion of the vagina with the organ, and pressing in these situations as high as this may be done, more pain has been felt and complained of than is ordinarily experienced in other, and especially the healthful condition of the womb. Another symptom has been mentioned as peculiarly distinctive. “This is a pulsating, throbbing, or fluttering sensation within the vagina or pelvic cavity.” It is farther described, as differing much in degree in different cases,—is not constant, and is various in degree in the same patient at different times. I have met with sensations resembling these; but they were referred to situations above the brim of the pelvis, rather than to its cavity. I have not discovered tenderness in the vagina. Various disturbances in the uterine functions, occur in irritable womb. Menorrhagia is very frequent, while the catamenia may be deficient, in some cases, and amenorrhœa exist in others. Dysmenorrhœa is common. But perhaps the functional derangement which has been most frequently met with is leucorrhœa. One observer has never known impregnation to take place in a subject of this disease; while another has known irritable womb to continue through the whole of pregnancy.
The womb undergoes some change of place. It does not amount in the majority of cases, to what is understood by prolapsus, though in some the fall is considerable. It is lower than natural, but still not so low as to explain at all the symptoms of irritable womb. In the diagnosis it will be more fully stated in what the two diseases differ from each other.
Along with these uterine symptoms, and supposed to be connected with them in the relation of cause and effect, various general and local affections have been observed. So distinctly are they brought into view in this connexion, at least by one writer, and so clearly present were the leading pathognomonic signs of irritable uterus in his cases,—and more especially, so certainly were they removed by remedies addressed directly to the womb, that an account of this affection would hardly be complete which did not distinctly notice them. They may belong to predisposition alone, in particular individuals; but they were nevertheless so constant in numerous cases, that they can be gotten over only by supposing that uterine irritation did not exist, and that the author was describing some other disease. It is, finally, from the correspondence of my own observation with these views, that I shall next proceed to describe some of the general, and sympathetic local affections with which this disease has been observed to be accompanied.
No diseases affect the whole aspect of the female more strikingly than those of the uterine system. This, which is especially true of its organic affections, is true also of its functional. The physiognomy, if I may so apply the term, of all these disorders, is so marked, that the accurate observer may almost infer from it, not only the seat, but often the nature of the malady. The exceptions are individuals of originally firm constitution, who are plethoric, and fleshy, and in whom the disease has been induced by the force of the exciting causes acting on an organ possessing no special predisposition to this or any other malady. Time will, however, reduce even these to a very near resemblance to those of a very different constitution. The general aspect in irritable womb, manifests great debility; the skin is pale, and the more so, as menorrhagia, and especially leucorrhœa exists,—the flesh is flabby,—the countenance anxious, or expressing not only a present suffering, but bearing the traces of much and frequent misery. If we observe the motions of the patient, such movements as the ordinary courtesies of a visit may give rise to, we shall find these made with care, and obviously with increased uneasiness, if not positive pain. I have known turning in bed, or merely moving in a chair, to be accompanied by such expression.
If we examine the pulse soon after our arrival, it will be found rapid, and it may be small; but while we are feeling it, we may find its numbers rapidly to diminish, and a greater fulness developed. The pulse may even become slow and soft, losing these characters however under any new excitement of the moment, and then shortly again acquiring them. The pulse may in other cases be permanently rapid, and small, and hard,—or frequent, full, and soft. Its state then is not to have an undue influence either in diagnosis or treatment.
Headach is a frequent symptom of irritable womb. It may take a chronic form, being in some cases always present in variable degrees; in others occurring from very slight causes after various intervals of ease. Confusion of head,—imperfect vision,—ringing in the ears,—throbbing,—depressed spirits, with difficulty of fixing the attention long on any thing but the patient's own personal troubles, are also among the symptoms which may be referred to the head, and the cerebral functions.
In the thorax, we have pain, especially below the left mamma, and about the edges of the ribs of the same side. This pain may, and does in many cases exist entirely by itself, unaccompanied either by dyspnœa or cough, or by increase during respiration, however full and deep this last may be. It does indeed exist along with the symptoms which are ordinarily associated with severe local pain in the chest, however circumscribed, such for instance as pleurisy. Cough is one such complication; being in some a dry, suppressed, hecking cough; while in others it is full and sonorous. Long before irritable uterus had been pointed out as a peculiar affection, this had been noticed, and the appropriate designation of “uterine cough,” had been employed to express it. Some times there is hemoptysis. I have met with this last always alarming symptom, (though always least alarming to patients suffering uterine irritation) in an unequivocal case of the disease, which was accompanied with severe menorrhagia, with leucorrhoea, and distressing headach. This was in a young woman of eighteen, of a full plethoric habit, who had in early life been of very active habits, and who had suffered much general disturbance from passing suddenly to sedentary occupation, and in whom the uterus had early manifested functional derangement.
Pain in the left side is sometimes attended with violent palpitation, acute pain in the precordia, and great dyspnœa. The sufferings of such patients are intense, and exercise is rendered impossible. Now, during this effect of uterine irritation originally, and during the positive rest imposed on the patient, the local uterine irritability may greatly subside. True hysteria is at length fully developed, and so disguised may this be, that nothing short of acute inflammation, with organic disease of the heart or the lungs, can be believed to be sufficient to produce the symptoms. I have met with an extraordinary case of this kind. The attack was reported to have been sudden, and up to the time of the invasion of the thoracic symptoms the uterine function was stated to have been healthful. For the violence of the dyspnœa, and the exquisitely painful palpitation, bloodletting was resorted to in the failure of all other employed means to give relief. Relief followed, and so did a paroxysm. Bloodletting was repeated again and again, so that at the end of two years and a half from the first attack, and at the time when I first saw her, I learnt she had been blooded ninety-three times. Her appearance was quite remarkable. The whole surface, the tongue, and inside of the mouth were bloodless. There was not extreme emaciation; the appearance was most like that of a woman, of nearly average health, who had just escaped with life after uterine hemorrhage. Her voice was extremely feeble, and her countenance contrasted strongly with the unusual brilliancy of her large dark eyes. The pulse was one of extreme irritation. The superficial veins, to the smallest noticeable ramifications, contained blood of a bright arterial colour. She suffered severely from headach. The appetite was almost nothing, and I learnt she had lived during her long and exhausting illness upon the smallest amount of food. Soon after I saw her, she was seized with a very severe paroxysm. Receiving but partial relief from the various means used, and having been most urgent for a repetition of bloodletting, pleading for it as the only means of preserving life, or of making death more easy, her demands were acceded to, and six or seven ounces of blood were extracted. Relief was obtained. The greatest difficulty was experienced in suppressing the after-hemorrhage from the orifice in the vein. The blood flowed as from an artery, and much was lost before it was controlled. It seemed as if the communication between the arteries and the veins had been so much changed from their natural state by previous bleedings, or other causes, that the two formed common canals. This patient soon passed out of my observation, and not long after died. Examination after death did not discover the least disease either of the organs of the thorax or abdomen, and no effusion. The greatest paleness existed every where. The womb was not diseased. The ovaries were both enlarged, and that on the left side was dark, as if from congested or coagulated blood. I was not present at the examination.
Pain in the right hypochondrium is also named amongst the symptoms of irritable uterus. This in many cases exactly imitates diseased liver, and in all resembles it so nearly as to be taken for it. The ordinary treatment of that disease answers no good purpose in this imitation of it, except where the secretions are manifestly disturbed. It is probable that these symptoms belong to an exceedingly irritable state of other abdominal organs, particularly the large intestines. Of these the colon is the principal one, and in various portions of this organ, or in different parts of the abdomen, its morbid condition discovers itself. It does this most frequently in the form of severe colic. I may add, that this is a most troublesome and distressing complication in these cases,—that it is very easily excited,—that its causes are avoided with great difficulty, however prudent may be the patient, and that the professional management of it is sufficiently embarrassing.
Another symptom under this head is tenderness, with or without tension of the abdomen, which, with the increased heat of the surface, and the accelerated pulse attending it, might lead to the notion that peritonitis was present. This tenderness is sometimes so acute that the slightest pressure, even of the bed clothes, is almost intolerable. In some cases the pain affects the epigastrium, and in others, the lumbar or iliac regions, and is frequently accompanied with distinct swelling of the part. The stomach suffers in this disease, either from direct sympathy with the womb, or from taking part with other organs in the general disturbance which is induced. The bowels are also disturbed in their functions, costiveness being the most common form under which this is manifested. Pain is also complained of in the kidneys,—course of the ureters, and in the bladder, the pain in the latter being accompanied with dysuria.
I have now described irritable uterus, and I go on in the next place, as was proposed, to inquire into its nature, and to offer some explanation of the facts which have been brought into view.
The terms irritable and irritation have been adopted, not because they are considered to be the best, but rather for the purpose of distinguishing the disease from others with which it was forseen it would be easily confounded. Inflammation is such a disease; and though perhaps in its simplest forms it is not very frequently met with in the womb, still it has symptoms sufficiently like those of irritable womb to be mistaken for it. Irritable womb has been in fact regarded as depending on a modified inflammation of the neck of this organ. There is another condition of the organ which may lead to error. It is that in which inflammation cannot be said strictly to have taken place, in which the small vessels are impaired in their functions, and an increased sensibility has been developed. Now these are accidental states, produced without the agency of any long-existing predisposition, which may disappear at once, when the partially deranged functions are restored, or by a temporary removal of all exciting causes.
Farther;—Inflammation is a disorganizing process. This fact has been particularly referred to in the history of irritable womb. Inflammation can hardly continue a long time without affecting the structure of a part; and what is the structure of that portion of the womb which is the principal seat of our disease? The neck of the womb approaches most nearly to the glandular texture, in its functions and in its diseases. Its principal function is the secretion of a dense, viscid substance, by which the os uteri is sealed up during pregnancy, and this secretion is only performed during this state. Its diseases are organic degenerations,—adventitious structures, malignant in their nature, and exquisitely painful in the greater number; such diseases in short as are commonly met with in glands. Now inflammation attacking such an organ, and continuing without interruption for the very long time which irritable womb, under the most favorable circumstances, may and does continue, could hardly fail to produce structural changes. The part would at least be enlarged, and its natural softness be destroyed. I do not say that specific malignant disease would be the consequence, but such disease as would, at least in many cases, be obvious to some of the senses. Now such changes have not been observed in irritable womb. The structure remains mainly the same as in health. This organ has hardly ever been found notably enlarged, or hard. I have, I think, felt the os uteri or its labia in some few instances to be somewhat fuller than in health, and in one or two, a little irregular in outline. But even in these the part was soft, and was at once discovered to want the peculiar feel, which characterises either organic disease, or even simple chronic inflammation of the same part.
The doctrine, that irritable womb depends on inflammation, has been supported by the beneficial effects of blood-letting, whether general or local, in certain cases. But is this remedy confined to inflammation? Does it not, on the contrary, exert its best influences where there is no suspicion of inflammation, namely, in exquisitely painful and spasmodic affections, where the sensibility is greatly exalted, and the action of certain textures, the muscular for instance, is violent, but in which not a single process of inflammation is supposed to be present? But the propriety of blood-letting has been seriously questioned, except in rare cases of irritable womb. It is not, in short, regarded, at least by one writer, as having a place among the remedies of the disease. If we, therefore, take into account the long time this disease may continue,—its small, if any, tendency to destroy or alter the structure of an organ very prone to undergo morbid changes, and finally, the treatment which in most cases has been found curative, have we not reason to doubt the correctness of the doctrine which ascribes it to inflammation, and to regard it as a peculiar affection, marked by symptoms belonging to itself, and requiring a particular treatment?
It has been attempted to remove some of the obscurity which attaches to the pathology of irritable womb, by the analogies of other diseases. These show that there are painful affections of other organs; that these may continue a long time, and though existing in parts in which chronic disease is extremely apt to become malignant, these are nevertheless unattended by any sensible morbid changes in structure, nor do they produce such. “Thus,” (says Gooch) “surgeons describe what they call irritable tumour of the breast. It is exquisitely tender; an ungentle examination of the part leaves pain for hours; it is always in pain, but this is greatly increased every month immediately before the menstrual period. Although apprehensions are entertained of cancer, it never terminates in disease of structure. It is represented as a very common disease. Mr. Brodie describes a similar state in the joints. It occurs principally among hysterical females; it is attended by pain, at first without any tumefaction; but the pain increases, and is attended with a puffy, diffused, but trifling swelling, the part is exceedingly tender; this assemblage of symptoms lasting a long time, and being often little relieved by remedies, occasions great anxiety, but there never arises any ultimate bad consequences.” “The disease,” says Mr. Brodie, “appears to depend on a morbid condition of the nerves, and may be regarded as a local hysteric affection. These painful states of the breast and of the joints appear to be similar to that which I have been describing in the uterus; similar in the kind of constitutions which they attack; similar in pain; in exquisite tenderness; in resemblance to the commencement of organic disease, and in proving ultimately to be diseases only in function.” Without now forcing analogy beyond the limits ordinarily assigned to it, though something wide of a truly philosophical warranty, may we not trace as close an alliance between irritable womb and irritable spine, as between these anomalous diseases of the joints and the mammæ. The spinal affection is, by the structure of the parts in which it occurs, so far removed from external pressure, that exquisite sensibility may not always be manifested. Still this is often present in the vicinity. But what shows its near resemblance to the other diseases referred to, and also to irritable uterus, is the great increase in most cases of its local and sympathetic affections when pressure is applied. What is still more to our present purpose, is the fact that the tendency to organic changes is no greater in this than in irritable womb. The suffering is great, the disease may continue a long time; the constitution may suffer; the spine may get curved from the posture assumed and continued by the patient to get rest, just as the irritable womb prolapses a little in the general weakness accompanying it, its supporting ligaments losing their tone; but with all this no morbid lesion is produced in the spine, no such changes in structure as the long continuance of such serious local symptoms might lead us to apprehend.
When now, these facts are considered, and when we take into connexion with them the peculiar irritability of the female constitution; the acknowledged agency of the uterine system in its most healthful as well as its morbid conditions, shall we be far from the truth, if we consider these and many kindred affections as essentially the same, their affecting particular parts or organs depending on special predisposition, or mere accident? I am disposed to take this view of the matter, not only from its being most convenient, but because, as I believe, it is the nearest approximation to truth. We have then only to look to one great cause in our philosophising, which is in conformity with one of the best established principles of philosophy, and may at once arrange all contingent phenomena under natural classes. In place then of multiplied treatises on particular and novel affections, our generalizations will be at the same time short, simple, and practical. The authority of fashion will cease to embarrass the profession in this regard at least, and doctrines once wisely established, will not be lost sight of in the supremacy of some ingenious novelty.
Diagnosis. Our subject presents few if any points of so much interest as this. This interest arises from the following considerations. The disease has not been, until recently, adverted to, I might say known. It bears a very close resemblance to other diseases. Finally, the treatment of such diseases does not answer any good purpose in irritable womb; but on the contrary, may aggravate it, and prolong its continuance.
Prolapsus Uteri. This exists in some degree in the majority of cases of irritable uterus; but rarely in any to such an extent as would give rise to any serious inconvenience, if existing alone. They have many symptoms in common,—the menorrhagia, the leucorrhœa, the bearing down, and other local difficulties, all aggravated by exercise, and the erect posture. But they have, with all this, quite sufficient for diagnosis. Prolapsus ceases entirely to be painful in the recumbent position. Irritable womb does not. There may be a diminished suffering in the latter, but the essential symptom remains; and if there has been much exertion made, or standing been long persisted in, very severe pain continues some time after lying down, and a less degree of it is constant.
Examination will however always settle the diagnosis, and this should never be omitted, not only in this, but in all serious affections referable to the uterine system. A physician can know, I may say, nothing of this class of diseases in any other way than by examination per vaginam. One of the very best writers on female diseases declares he would not consent to undertake the management of any such affection, but upon the condition that an examination were allowed to him. No objections should stand in the way of making one. Examination in the diseases in question discovers in irritable womb, pain more or less acute in the neck of the organ; in prolapsus nothing more than the healthful sensibility of the part.
Dysmenorrhœa. This is a frequent symptom. A state of morbid irritability is not favorable for the performance of a natural function; and we can easily understand how the conditions of menstruation, and the function itself, should be very painful in irritable uterus. The whole pathology of the womb teaches the same thing. Dysmenorrhœa is however a disease by itself. It is an accident to uterine irritation. The two may be easily distinguished. When alone, dysmenorrhœa is manifested only during menstruation. The intervals of periods may he passed without any suffering, though the patient pursues all her customary avocations. Exercise, and long standing do not produce it; and rest, however perfect, does not diminish it. It is not attended by any important sympathetic affections. Examination here, as in the last, will determine the diagnosis.
Menorrhagia and Leucorrhœa. These are symptoms of many diseases of the womb, and of themselves frequently form a distinct class of functional disturbance. These affections, or their causes, are readily discovered by examination. Extreme caution is required in their management. If they depend, as they may, on structural lesions, to check them suddenly will be to precipitate the patient into the worst stage of the disease which they accompany, and which within a certain range they keep in check. Even in mere congestion, or the slightest degree of inflammation, the increased function, while it is a sign of such state, is for the time a means of checking its progress, or a very useful auxiliary in conducting to cure. When, however, they are wholly dependent on irritation, local means to put a stop to them, especially leucorrhœa, are among the means which will be found curative; and their good effects confirm the diagnosis.
Organic Disease. This has two forms, malignant, and non-malignant. The first attacks for the most part, if not exclusively, the os and collum uteri. Some of them are exquisitely painful, and in most morbid sensibility prevails. They are attended by other symptoms of irritable womb. Pressure on the diseased part, as in that, enhances the pain. Lancinating pain belongs to them equally. But the state of the mouth and neck are widely different. In the malignant malady, cancer, &c., we have striking sensible changes. The os uteri is open, ring-shaped, uneven, gristly, hard, or as Dr. Wm. Hunter has it in his manuscript lectures, having a “cancerous feel.” The diseased part is increased in size, or a great portion eaten away; not increased so much indeed as other portions of the womb are in many diseases, the fleshy tubercle, for instance; still it is enlarged, and whenever so, is very hard. Nothing of this sort belongs to irritable womb. We come from the examination surprised to find that in an assemblage of symptoms, which can hardly seem to depend on any thing but organic change, the mouth and neck of the womb have undergone little, if any, alteration. Slight fullness may indeed be sometimes noticed, and perhaps slight swelling of the neck; but the os uteri is even more closed, if any thing, than natural, and the healthful softness in all parts remains. The diagnosis here is most important to the patient. We can at once assure her, if irritable womb only exist, that she has not a disease that is tending to destroy her life, or is malignant. It is acutely painful to be sure, and may take months or years to wear itself out, or to be removed by art, but her life is not endangered by it.
In the other form, the non-malignant, the diagnosis is less embarrassed. There may be disordered functions, menorrhagia and profuse leucorrhoea, but there is not the exquisite tenderness on pressure, nor the same increase of suffering on exercise, and examination detects the enlargement of the organ, and the increase of its weight. The sympathetic affections are not the same; and if they do imitate those of irritable womb in their localities, it is in this circumstance mainly that the resemblance will be found.
Simple Chronic Inflammation of the Womb. Between this and irritable uterus there are very striking resemblances. It occurs most frequently in married women; though occasionally about the age of puberty; is accompanied with symptoms of general irritation; uneasiness or pain in the back, hypogastrium and thighs; frequent desire to pass water, with increased suffering on exercise; leucorrhœa; tenderness of the os uteri; dyspepsia, costiveness, and various sympathetic affections. Examination discovers the womb to be lower than natural, with elongation of the cervix; and great tenderness of the organ on pressure. Here is a case of simple uterine irritation. The diagnosis is to be learnt from another portion of the history of simple chronic inflammation of the womb. In this we have enlargement, gradually produced in most cases, but sometimes it would seem suddenly. The general fulness of the organ, with swelling of the neck, are quite obvious, and are accompanied with more or less embarrassment in the functions of the bladder and rectum. Now if the patient make any considerable bodily effort, or continue long in the erect posture, she is liable to be seized suddenly with exquisite suffering within the pelvis, and if examination be made, the womb will be found more or less completely retroverted, and too tender to bear the least pressure.
The diagnosis is farther aided by the effects of the treatment employed in this case. If this consist in an active use of antiphlogistics, as general and local bleeding, purgatives, nauseating and promptly alterative medicines, we shall find the symptoms rapidly to decline, the enlargement of the womb to disappear, its natural situation regained, and in two or three weeks the patient well, and as perfectly so as after recovery from any other severe attack of common inflammation. The treatment of irritable womb gives us no parallel results.
Spinal Irritation. I regard the diseases as so much alike in kind, that the diagnosis is resolved into the simple question of the seat of the disease. True, the irritation may exist in both places in the same patient, less declared however in one of them. It may be in the womb that this may be the case, or it may be in the spine. I have known irritable womb to exist in an exquisite form and for a long time, uncombined with any spinal affection. It has at length worn itself out, or has been removed by remedies, and then excessive tenderness of the spine has occurred, becoming the leading malady, and marked by its special symptoms. Now these symptoms are very often those which characterise true hysteria, in fact it is hysteria in its most perfect and sometimes most alarming forms. We have here either a conversion of the disease or an unexplained but original manifestation of it in a new situation.
Effects of Remedies. In aiding diagnosis, this is in many diseases, an important means. It has long been recognised as such. Sydenham has acknowledged its value on the invasion of new epidemics, and in the management of diseases which only wear their livery. Its importance has been lately shown by Gooch, in his Treatise on Puerperal Fevers. It appears by this record, that a disease follows delivery, which closely resembles the severest kinds of puerperal peritonitis, but in which the best established treatment of the latter is not only hazardous, but if continued, because the symptoms continue, will surely end in death. Cases are given of this issue, and examination after death showed how misapplied had been the treatment. Not a vestige of pre-existing inflammation could be discovered. There are forms of uterine irritation, like this peritoneal irritation, in which similar mistakes may be made. I refer to the hysteric, and especially to those in which the lungs, the heart, or peritoneum, seem to be the seats of grave disease, viz. severe inflammation. The active treatment of inflammation has been tried in these, and the result has been an increase of the disease, the increase being in proportion to the continuance of active measures for removing the aggravated symptoms of the supposed inflammation.
From the foregoing description of irritable womb, I propose the following classification of its cases:
I. With menorrhagia—dysmenorrhœa,—and leucorrhœa,—excessive uterine irritation—and the sympathetic affections of the brain, thorax, and abdomen enumerated.
II. With slight functional uterine disturbance,—uterine irritation excessive, the sympathetic affections moderate and not constant.
III. With much functional derangement of the womb,—slight uterine irritation; the sympathetic affections being paramount.
IV. Complicated with, or following spinal irritation; Hysteria being predominant.
Under some one of these classes may be arranged the cases which have fallen under my notice. Some of them indeed might seem equally to belong to two if not to the whole four, for the complications in some cases are very remarkable, and render an attempt at an arbitrary arrangement sufficiently embarrassing. The above division is suggested on account of its practical bearings. It is very certain that the treatment of irritable womb must have regard to the whole condition of the patient, as well as to any particular local affection, with which that condition may be associated.
Prognosis. This should be favorable as to the whole result, but very cautious as to the time the disease may continue. The physician has an interest in this as well as the patient. The latter should be as well prepared as circumstances will allow for protracted discomfort, and for submission to a course of treatment which will demand many sacrifices. The physician will escape the embarrassments which great mistakes in prognosis sometimes involve. The prognosis should be favorable from the known result of cases of great severity and long continuance. The disease has no tendency in itself to produce organic and malignant degenerations, and treatment may do much to diminish the constitutional derangements which belong to the disease, and which may result in great exhaustion. This last may predispose to other and serious disease. But the patient is happily removed from existing causes; and direct observation has shown how rarely are its subjects the victims of other maladies.
Treatment. This has regard to the womb itself, and to the whole system. We may have to manage an idiopathic affection of the organ which has associated with it various sympathetic affections; or the disease of the womb is purely secondary, and is among the other consequences of general constitutional derangement. I have described the disease under various modifications; and cases exhibiting these may belong to either of the two most general divisions of subjects just referred to, and which were particularly indicated in the beginning of this discourse. Before giving the treatment which particular classes of cases require, I shall state what is of the most general application. And first, of Rest.
Rest forms an indispensable portion of the management of all cases. It is the condition on which the success of the whole treatment depends. Of its importance the patient should be fully informed; and especially of the hazard she runs of aggravating the disease in all its forms, by neglecting this condition, and of reviving the disease when it may be about wholly to disappear. Am I asked of what kind, and how long, shall rest be insisted on? I answer, it is the recumbent posture, on a bed, or a sofa; and as to the time, certainly so long as the erect position produces uneasiness, and while this has associated with it the sympathetic affections which have been described as belonging to the disease. The cases in which rest has been found demanded most imperatively, have been those in which the tenderness of the womb has been most exquisite, and in which severe paroxysms of pain have been produced by the erect posture, and especially exercise. Slight displacement of the womb belongs to many cases; this is increased by standing or walking, and can hardly act otherwise than to increase the disease as well as the suffering.
Digestion is impaired, and costiveness a very common symptom. The treatment should have both in view. The diet should be such as will require least of the stomach, and still yield sufficient nourishment. What will do this must be somewhat matter of experiment; or the patient may have already learnt it by her experience; but as a general rule, such food must be directed as is least stimulating, especially among liquids, and such other food as will be least likely to undergo chemical changes. Flatulence, particularly of the bowels, is very common, and exceedingly distressing. It depends very much on the state of the bowels, as it regards tone, but it is always more or less connected with the quantity and quality of the food. Costiveness is to be prevented by diet, if this be practicable, or to be removed by such means as will answer the purpose with the least irritation. The best articles are sulphate of magnesia, castor oil, and rochelle salts. The secretions are frequently morbid, as showed by the evacuations. Diet and regular bowels may do much to restore these to a natural state; but, if not sufficient, a gentle alterative course may be usefully adopted.
Pain is a common symptom in all cases, and may disturb the patient at night as well as by day. In prescribing for this symptom, we select such articles as diminish the sensibility and promote sleep, but which will leave the least trouble behind them. The sub-narcotics are of this kind, as the conium, the hyosciamus, the common hop, poppy, camphor, &c. The extract of taraxicum, given with one of the above, has been thought to exert a very useful alterative agency, and this agency may be always increased by adding a minute quantity of the blue pill. Opium may be required to produce relief, or to procure sleep. The preparation which has been thought to answer best, is the solution of the salts of morphine, or narcotive. The old fashioned tinctura opii will probably be found to answer every desired purpose quite as well, as any of its modern substitutes. Rest, then,—regulated diet,—strict attention to the bowels,—relief from present suffering, and the procurement of sleep, are among the points which are of special importance in the management of all cases.
I shall next state very generally the treatment which particular forms of the disease may require; and I shall, in doing this, refer to the classes under which I have comprehended its various cases. First, of those in which functional disturbance, and severe sympathetic symptoms exist. It is advised in these cases to address the treatment in the first place to the womb itself; next, remove or palliate painful symptoms, and lastly restore the general health. We must have regard to the presence or the absence of the catamenial function in beginning the treatment. If menorrhagia be present, positive rest and light diet are to be enjoined; local or general blood-letting should be premised if the general state of the patient as to plethora, activity of circulation, or severe pain in the pelvis without general disturbance, make either necessary. When the period has passed, cold astringent injections, per vaginam, should at once be directed. They are to be continued daily until the expected recurrence of the catamenia. If menorrhagia be not present, nor the usual catamenial discharge, and the pulse not indicate bleeding, we begin the use of injections at once. Suppose irritable womb be accompanied with dysmenorrhœa, and slight or no leucorrhœa. The injections are to be employed at once. So in leucorrhœa alone, the catamenial function being healthful.
The sympathetic affections depend on the uterine irritation. These will continue while their cause remains. They may have already continued so long, that they may not disappear with their cause. Much of the treatment of these symptoms has been referred to when speaking of means which are applicable to the great majority of cases. And of others our treatment is little more than palliative. If good evidence exist of great vascular action with plethora, bloodletting, general or local, or both, will be proper.
But if we have tried this, especially venesection, much caution is to be observed in its repetition. Partial relief at first, with speedy return of suffering in the old place, is no good reason for continuing blood-letting as a part of the treatment. It may be necessary to bleed or cup a second time, but much caution is to be exercised. This becomes of much stronger obligation in the advanced periods of the disease, when exhaustion is manifested every where. Let the local symptoms be as severe as they may, it is questionable if the loss of blood will give even present relief; and it will surely be followed by increased suffering. Suppose the local trouble be pain under the left mamma. Hot applications, and active rubefacients may give temporary relief. To these may be added the internal use of the aqua ammoniae, which if given along with magnesia in small doses, in camphor mixture, has been found singularly tranquillizing; and the above named subnarcotics may be employed at the same time, or trusted by themselves. These are palliative only, it may be; but while they are employed, the astringent injections will be effecting salutary changes in the organ primarily diseased. Pain in the abdomen, and in the right hypochondrium, with disordered secretions, may be relieved in the same way. For the last, the alterative use of calomel, or blue pill is recommended. Warm bathing is frequently useful as a palliative in most of the affections incident to irritable womb.
In the second form of the disease, in which functional uterine disturbance is slight, but the irritation excessive, with trifling sympathies, local bleeding in the neighbourhood of the womb, has with Gooch, and some others, a principal place. Cupping is preferred to leeches. It may be done at the upper part of the sacrum. Leeches, if used, are to be applied to the hemorrhoidal vessels, or between the labia pudendi. But a caution follows the recommendation. We are to have regard to the time of the disease, and the state of the patient; and four ounces have in some cases done all that could be looked for from the remedy. Sometimes, one of the best friends of bloodletting acknowledges, the remedy only does harm. It aggravates all the symptoms, and, says he, “the effect was unmixed misery.” This is an acknowledgement worthy of all honor. The same caution is added to all that is said of the good effects of mercury in this disease. This may very soon become an active agent in the production of evil, and without much watchfulness, we may continue its use to overcome what it has itself mainly produced.
In these cases all the palliatives before named, are to be faithfully tried. I should in this class use the astringent injections so strongly recommended in the first, under similar conditions. I should not omit to recommend here the employment of local irritation; viz. caustics, blisters, &c., in the neighbourhood of the pelvis. The best place is the upper part of the sacrum. Of the size of a dollar they will answer every purpose, and may be advantageously renewed when healed.
The treatment of the third class of cases should be conducted on precisely the same plan as the first. The astringent injections will be found equally serviceable in both.
The fourth class embraces cases complicated with spinal irritation. This is not a small class. It has not been distinctly recognised, but wider observation, I have no doubt, will show how nearly related are the two diseases. Whenever, then, we have to manage hysteria, whether the derangement of the uterine functions, or the diagnostic symptoms of uterine irritation be present or not, it is worth recollecting that spinal irritation frequently exists at the same time with them, and that its removal may be followed by the disappearance of the hysteria. The irritable uterus is to be treated in the same way as in the other classes already described.
A patient who has suffered from this disease, and in whom salutary changes have occurred, will still demand much attention during convalescence. She is to be guarded from the existing causes of the malady, and is, at the same time, to use means for the restoration of health. Among these are diet, tonics, change of air, and exercise. The best tonics are chalybeates; and these, as they exist in natural mineral waters, are best. They frequently contain mild cathartic salts, which add to their usefulness. The situation of such waters, and a moderate indulgence in the gaiety which is almost native to them, are highly salutary. I have said nothing of the benefit frequently derived from the use of preparations of iron at an earlier period in the disease. The solution of the sulphate of iron is particularly to be recommended. I have never known it do harm after excitement has been subdued. On the contrary, I have found it highly useful as an aid to the other treatment of the functional derangements of the uterine system so common in irritable womb. The pessary will also become a very important means of preventing relapse when the removal of the local irritation allows of its use.
In the preceding discourse, a large place has been given to local irritation as a cause of many of the symptoms which attend the diseases of women. It has not been my purpose to give it a larger one than it deserves. I have endeavoured, by reference to facts in as much detail as circumstances have allowed, to support a doctrine which I believe to be well founded, and which leads to useful practical results. I perhaps owe to the Society an apology for the minuteness of description into which I have been sometimes betrayed. I will not plead for any indulgence which the circumstances of my appointment might make reasonable, though I will acknowledge that they may have influenced me in the choice of my subject. The time was quite long enough for preparation, but it required that the selection of a subject should be soon made.
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