1847] Gonorrheal Inflammation of the Uterus. 399 entertained, is nevertheless what might reasonably have been anticipated. In the first place, the gonorrheal virus, from physiological causes, is liable to be carried immediately to the highest part of the canal, and forcibly projected upon the lower extremity of the uterus, which organ also, at this juncture, is in a state eminently calculated speedily to absorb it; in the second place, the normal secretion of the vagina possesses properties which are capable, to a certain extent, of destroying, or of materially modifying the virulency of the morbid product, and of thus protecting the vaginal surface from its immediate influence. The urethral orifice, however, seems to be provided with this means of protection in a much less perfect degree, and is, therefore, more highly susceptible of the action of specific inoculation. In nine unimpregnated women afflicted with gonorrhoea, seven had inflammation, with abrasion of the labia uteri, and in the remaining two, the inflammatory action was confined to the vaginal surface; the parts beneath the arch of the pubis being most severely affected: in one of these the urethral orifice was also involved. "The first change operated upon the uterus after gonorrhoeal inoculation, consists in superficial inflammation of one or both labia at their most depending part, or at the boundary of the os and commencement of the internal cervix. The inflammation seems to affect principally the small mucous follicles with which the surface is closely studded-(probably not the Nabothean bodies already noticed). A small red patch is first perceived; sometimes there are two or three isolated spots which extend and soon run together, forming one patch, of variable size in different cases and in different stages of the complaint, and generally of irregular shape. On removing the thick secretion with which this is covered, the surface appears to consist of minute granules, equally dispersed over every part of it; the abrasion is bounded by a margin not very distinctly defined, running imperceptibly into the erysipelatous redness which surrounds the sore; this extends to some distance upon the cervix, the whole of which is more or less tumid, but not painful to the touch." P. 362. He subsequently adds: "I have seen no small number of cases of this disease, and have almost invariably found the lower part of the uterus inflamed or ulcerated; where the urethra or the adjacent structures have been involved, the affection of these parts has been proved to be of secondary character, resulting from a transfer of the morbid product from the seat of the primary inoculation-the uterus." P. 365. Gonorrhoeal inflammation is said to be extremely liable to extend within the cavity of the womb, and give rise to chronic Endo-uteritis; a distressing affection, which may exist for years, "rendering the whole of each succeeding pregnancy a period of suffering and misery, in many instances occasioning abortion at different stages of the process; sometimes it effectually prevents the accomplishment of impregnation, and it is not an uncommon cause of dysmenorrhoea. The symptoms are always aggravated during pregnancy; the inflammation involving the deeper textures of the cervix, and resulting in interstitial deposit, and consequent induration." Our author seems to be of opinion that a very large proportion of the cases of ulceration of the uterine mouth and neck are of gonorrhoeal origin. We need scarcely say that, in his opinion, the application of the nitrate of silver and other astringents must be made directly to the os and cervix uteri in the treatment of gonorrheal inflammation. He says that the patient herself may be taught how to apply any fluid remedy, with the aid of a speculum. Injections he declares to be of little use. EE * Passing over the subject of Syphilitic disease of the uterine orifice, we shall briefly notice one or two points in our author's description of Prolapsus uteri. He maintains that this disease of the organ, like abortion, is more frequently owing to inflammation and ulceration of the lower part of the organ than to any other cause. With respect to the treatment of this very distressing affection, Mr. Whitehead expresses his strong objection to the use of pessaries in the generality of cases; nay, he goes so far as to assert that "they invariably aggravate the disease for the relief of which they are employed." After pointing out the necessity of attending to the general or constitutional health of the patient, he remarks :— "The local treatment should consist in applications of nitrate of silver, or other suitable remedies to the diseased surface, and in the insertion of medicated tents by the aid of the Prolapsus tube. This latter procedure may be practised immediately after the nitrate has been applied, although the remedy with which the tent is charged be of a very different nature from that of the caustic. "The manner of using the Prolapsus tube-which will be found of equal service, in the management of prolapsed displacement of the uterus, as in most other forms of uterine disease, and enables the patient safely and efficiently to apply the remedies herself, without the interference of the practitioner-is extremely simple. The charged tent, to which a length of thread has been previously attached in the manner before directed, must be placed in the tube, the upper orifice of which is to be applied against the protruded portion of the uterus, in such a manner as to receive the os uteri within it. The instrument, previously smeared with some unctuous material, and having its curved arm placed anteriorly, in a direction towards the abdomen, is now to be forced gently and steadily backwards, until the whole, or greater portion of it, has passed within the canal, or until a moderate degree of resistance is felt to oppose its further ingress." P. 394. "The uterus being thus restored to its natural position, the tent or pledget must be pressed upwards against the cervix, and held in that situation by means of a skewer or other suitable instrument, the tube at the same time being gently withdrawn. The recumbent posture should be strictly maintained for several days, and very little exercise taken for some weeks afterwards. The cases recorded in the accompanying table were those of poor women, obliged, during treatment, to pursue their domestic duties, which constantly and seriously interfered with the favourable effects of the remedies; hence the reason, probably, why most of them were so long under treatment. The application should be renewed daily, or twice a-day if convenient." P. 395. The lotions, used for moistening the lint-tent, are strong solutions of nitrate of silver, sulphate of zinc, sulphate of copper, matico, opium, and tannin. The metallic proportions should not be employed oftener than every third or fourth day, the vegetable applications being used intermediately. An emollient injection should be made use of after the removal of each tent. We shall now briefly advert to the contents of Mr. Whitehead's last chapter, that which professes to treat of Sterility. His remarks upon the fatal influence of abnormal states of the vaginal mucus on the vitality of the spermatic animalcules need not detain us; most of them are mere conjectures; not his, by-the-bye, but those of M. Donné whom he quotes. As to the morbid conditions of the uterus, which he enumerates among the causes of Sterility, endo-uteritis-endo-metritis would be a better word -and ulcerative inflammation of the cervix are declared to be the most 1847] Illustrative Cases. 401 frequent. It will be our best plan briefly to analyse a few of the cases adduced by Mr. W. in illustration of his views : 1. A woman, aged 41, was admitted into the Manchester Lying-in Hospital, eight months advanced in her second pregnancy. She had been married when 18 years of age, and borne her first child a year and a half subsequently. After this period, she was seldom free from leucorrhoea, which was often of an acrimonious character, during the menstrual intervals. The catamenia were tolerably regular, but always attended with great suffering. Her husband survived sixteen years; and, a twelvemonth after his death, she married a second time, her health having somewhat improved in the interim. "Two years and three quarters after marriage she experienced an attack of fever, for which she was an in-patient of the Manchester Fever Hospital, after which she enjoyed excellent health: the fever having set her up.' All symptoms of uterine disturbance disappeared on the accession of the febrile affection, and did not afterwards return. Pregnancy took place eight or ten weeks after convalescence, and she was delivered in due time of a living child at the full term of utero-gestation. The uterus, which was examined previous to her dismissal from the Lying-in Hospital, exhibited traces of former disease, but was perfectly healthy." "cure We may pass over the next case, as there was unfortunately no effected. The one that follows is headed thus: Sterility fifteen years; secondary syphilitic affection of the uterus of sixteen years' duration; sanious leucorrhea; painful menstruation; pregnancy; cure. By-the-bye, is not the cart put before the horse here?-was not the cure before the pregnancy? The circumstances of the case are these. A young woman was infected with syphilis by her husband soon after marriage; she was never pregnant by him. He died twelve years afterwards; and then, after a twelvemonth's widowhood, "being then in a better state of health," she married a second time. Her general health became much improved, and, as might be expected, the leucorrhoeal discharge, with which she had been affected for many years, was much diminished. Two years subsequently, she became pregnant for the first time. As she was threatened with abortion soon after quickening, she consulted Mr. Whitehead. He found, on specular examination, the following appearances : "The cervix uteri was unusually large and firm; the boundary of the orifice was covered with granulations which appeared to extend to the interior of the organ; the outer boundary of this ulcer was marked by a raised margin, beyond which the surface of the cervix was of a dark-red colour and mottled; a fissure occupied the right commissure, from which and from the adjoining granulations blood was exuding. On communicating my suspicions respecting the syphilitic nature of the complaint under which she was labouring, her history as above given was related in a straight-forward manner; but she was unwilling to believe that any trace of the venereal affection remained in her constitution, so that no treatment was adopted having reference to that particular purpose. Her delivery took place on the 11th of July, 1846, at the full period of utero-gestation." P. 411. The child subsequently exhibited indubitable traces of venereal taint. The following case is certainly more satisfactory than either of the preceding : A lady, married at the age of 21, became affected a few weeks after marriage with purulent leucorrhoea, which was suspected to be of gonorrhoeal origin and treated accordingly. After the active symptoms were subdued, the discharge continued, more or less aggravated from time to time by exposure to cold, or after severe exercise; it was, also, always augmented a few days previous to each return of the catamenia. Menstruation was attended with greater suffering than formerly; the secretion was more abundant, continued several days longer than it was wont to do, being sometimes clotted, or grumous and offensive, and occasionally, towards the end of the period, mixed with membranous substances. This unpleasant state of things had continued, with varying degrees of severity, for six years: she had never been pregnant. The general health was much impaired. The local malady is thus described :-"The whole uterus was found in a state of inflammatory hypertrophy, painful under pressure; the cervix was slightly indurated; and an angry-looking granulating ulcer of irregular shape occupied the lower and inner parts of both labia, and appeared to extend within the orifice of the uterus, whence flowed a thin ichorous secretion." Although the ulcer is here described as angry-looking, we subsequently read that the speculum was used for the first time about a twelvemonth afterwards. How is this discrepancy to be accounted for? Under the use of alterative and tonic medicine, with the addition of astringent injections, the leucorrhoeal discharge became considerably diminished, and the general health was much improved. Six months later, she miscarried in the third month of pregnancy: this was in March. In the following November she again miscarried, "at the end of the 5th month." The rest of the report we shall give in our author's own words : "She now expressed an anxiety about her case, and begged that the necessary means might be adopted for its efficient cure. The leucorrhoeal affection was said to have become considerably aggravated previous to miscarriage, and appeared to be in a similar state a fortnight afterwards when the treatment was commenced. On the introduction of the speculum, which was now used for the first time, the cervix appeared unusually large, hard, exhibiting several patches of excoriation; two deep ulcerated fissures occupied, one the left commissure, the other the middle of the posterior labium; the orifice was surrounded by a bright red, inflamed surface, and the whole was covered with a sanio-purulent secretion, which became considerably mixed with blood during examination. The nitrate of silver was freely applied to all the diseased surfaces, as well as within the cervix, and was afterwards several times repeated at intervals of six or seven days. She also resumed the use of iodide of iron combined with extract of cinchona. At the end of eleven weeks, the cure was complete: every part of the uterus was perfectly healed and of normal dimensions and consistence; the mind was cheerful and happy, the health vigorous; and, for the first time since marriage, she was free from leucorrhoea. "She was delivered of a living child at the full period of utero-gestation, on the 25th December, 1846." P. 418. In the case that is next reported there was obstinate leucorrhoea of many years standing, and there was presumed to be "ulceration of the cervix uteri and probably endo-uteritis;" the speculum was not used. A strong solution of the nitrate of silver-3j. to 3vj. of water-was ordered to be used as an injection, directions being given that, in using it, the syringe 1847] Illustrative Cases. 403 should be introduced as high up as possible. After being employed five times, severe inflammation of the vagina came on; but this, in the course of a few days, subsided, and the patient improved rapidly. She afterwards spent a few weeks in the country, and returned in better health than she had experienced since marriage. The so-called mistake had completely cured the leucorrhoeal affection, and consequently the uterine disease also: she shortly became pregnant, and was delivered of a living child at the full term of utero-gestation, eleven months after the injection had been used. In the case that follows this one, the symptoms of chronic endo-uteritis were mistaken, our author says, by several practitioners for those of "spinal irritation;" in consequence of there being, along with a fixed uneasiness in the left groin and an almost constant leucorrhoeal discharge, “a violent pain, extending from the third dorsal vertebra to the sacrum." Upwards of four years had passed since the lady had miscarried about six months after marriage; she had never been pregnant again. "The lower part of the uterus was in a state of inflammatory hypertrophy; the labia were thickened and projecting, and presented the ring of vivid redness around the orifice indicative of internal inflammation. To these parts the solid nitrate of silver was freely applied; leeches were applied alternately to the sacral and hypogastric regions, and remedies of an alterative character were administered. At the end of three months, her condition being remarkably improved, although the leucorrhoeal discharge was still present, she became pregnant." It seems, however, that, as the pregnancy advanced, all her former distress returned. "Soon after quickening, attacks of intermittent pains similar to those of labour, came on, the discharge was mixed with blood, and my attendance was solicited for the purpose of facilitating delivery, which was considered as being near at hand. The cervix uteri was large, inflamed, and excoriated, and a granulating surface occupied the boundaries of the orifice. To all these parts the nitrate of silver was again freely applied; two grains of opium combined with an equal quantity of hydr. subm. were given, and the strictest quietude enjoined. On the following morning she was free from pain: she had scarcely slept at all, but had been perfectly tranquil the whole night. Anodyne remedies and applications of caustic, with due attention to the alvine functions, were found occasionally necessary during the remainder of the process, which terminated in the birth of a living child of full growth on the 5th of April, 1846." Subsequently, there was a renewal of the symptoms that had so long affected the health. Believing that it was the internal surface of the uterus that was the primary and chief source of the mischief, Mr. Whitehead ordered a weak solution of the nitrate of silver to be forcibly injected into its cavity. It caused no pain or inconvenience, and its use was followed by the most gratifying results. The operation was repeated ten days afterwards. "The first injection was introduced on the 24th September, since which, now more than eight months, she has not had the least symptom of her former or of any other ailment, nor has she since taken a single dose of medicine. She has the appearance of one in robust health." These cases will doubtless suggest some useful hints to the reflecting practitioner, and the successful treatment in two or three of them is highly |