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CHAPTER III.

OBJECTIONS.

THE EXISTENCE OF INFLAMMATORY ULCERATION OF THE NECK OF THE UTERUS DENIED BY DR. ROBERT LEE; PROVED BY THE RECENT RESEARCHES OF DR. WEST.

In the last chapter, I have given a rapid sketch of uterine pathology, or at least of the debateable ground in this department of medical science, based on my own experience and researches. In this sketch, inflammation and inflammatory lesions occupy the most prominent position, and by their presence are explained most of those forms of confirmed vital and functional uterine derangement which were formerly considered to be morbid entities, and described under the names of leucorrhoea, amenorrhea, dysmenorrhoea, menorrhagia, &c. &c.

These views have now been many years before the medical public, and although adopted and acted upon by numerous eminent practitioners, whose approbation has been my greatest and most valued reward, they have been denied or severely criticised and opposed by others. The opponents to this doctrine may be classed in two categories :-Firstly, those who deny entirely the existence of inflammatory and ulcerative lesions of the neck of the uterus, and consequently the expediency of instrumental uterine treatment under any circumstances; and those who, although not going so far, inasmuch as they admit the possibility of inflammatory changes occurring in the mucous membrane of the neck of the uterus, yet deny their ulcerative nature, and consider instrumental examination unnecessary or even prejudicial. Secondly, those who admit all the lesions of the cervix and body of the uterus which I have described, yet

differ from me as to their causes, symptoms, and pathological importance; denying that they exercise the influence over the general health which I have ascribed to them, or denying that they require the surgical treatment which I have stated to be so frequently indispensable.

Thus there are still some practitioners to be found who totally reject the correctness and accuracy of modern researches into uterine pathology. In their eyes, inflammatory affections of the cervix uteri are a mere delusion- -a thing that is not, a creation of the imagination. I cannot call these opponents "false observers," for they have not observed at all, and therein lies their strength. Had they "looked at Nature," they could not speak with the confidence which they evince. As yet, however, none have ventured to give utterance to their opinions in print; they are merely enunciated in private, and are the result of preconceived ideas. In close proximity to, but a step in advance of, these men of a past day, we find others on whose unwilling senses a certain amount of evidence has been absolutely forced, but who still explain away and try to ignore what they have actually seen. Foremost amongst these, I regret to say, is a physician of great and deserved eminence, who has contributed much to medical literature, whose talents all respect, and whose character all esteem, but who, in this department of science, has unfortunately done much to retard the progress of truth. I allude to Dr. Robert Lee, whom I am unfortunate enough to number amongst my antagonists; I say unfortunate, inasmuch as his weight and authority, in and out of the profession, have been a great barrier in London even to the investigation of my views. Dr. Lee denies entirely the existence of inflammatory ulceration of the cervix uteri, as will be seen in the following extracts from his paper read before the Medico-Chirurgical Society in 1850 ("Transactions,” vol. xxxiii. p. 270):

"In cases of obstinate leucorrhoea, I have often employed the speculum in married women, after I had failed to detect the existence of disease by the ordinary mode of examination. In some of these cases, there has been seen an unusual degree of redness of the os uteri, sometimes affecting the whole, and

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at other times limited to the inner margin, with or without swelling. The white, viscid discharge has been seen issuing from the os uteri. I have never seen ulceration of the orifice of the uterus in such a case."

Again, page 275, he says emphatically : "Neither in the living nor in the dead body have I ever seen ulceration of the os and cervix, except of a specific character, and especially scrofulous and cancerous."

And yet that Dr. Lee has seen one of the conditions, to which the term ulceration has been applied by nearly all the pathologists who have latterly written on this subject, is evident from the first few lines of the following description, which I find also on page 270:—

"At other times, both the lips are swollen, nodulated, and fissured, and the mucous membrane covering them intensely red, with an appearance of superficial excoriations or granulations, which are elevated above the surrounding surface. These apparent granulations are usually considered and treated as ulcers of the os and cervix uteri, but they do not present the appearances which ulcers present on the surface of the body, or in the mucous membranes lining the viscera, and they are not identical with the granulations which fill up healthy ulcers. They present the appearances often observed on the tonsils, which are said to be ulcers, and are not."

The above extracts show, that although Dr. Lee states he has never seen inflammatory ulceration of the orifice of the uterus, he has seen some of those conditions which I and my predecessors and successors term ulcerative that is, pussecreting, granular surfaces, denuded of epithelium by destructive inflammation. The difference between us, therefore, is partly one of words, Dr. Lee recognising and describing at least one of the forms of inflammatory ulceration that we recognise and describe. That Dr. Lee should consider such a state as the one he depicts in these extracts as unimportant, as not demanding any local surgical treatment which requires the agency of instrumental examination, that he should think it perfectly curable by general treatment, is another matter. For the present, I am satisfied with having thus demonstrated, by Dr.

Lee's own testimony, the existence of these cervical lesions. Dr. Lee teaches that these conditions are rare, and I am afraid that my testimony has but little weight in his eyes; but what will he say to that of Dr. West, of St. Bartholomew's Hospital? Dr. West, in his Croonian Lectures for 1854, "On the Pathological Importance of Ulceration of the Os Uteri," to which I shall presently allude more at length, states that out of 268 patients examined by him, at the Middlesex and St. Bartholomew's Hospitals, he found ulceration in 125. This testimony

as to the frequency of inflammatory ulceration, is of the more value, as Dr. West all but agrees with Dr. Lee in considering these lesions, although of so frequent occurrence, to be of little or no pathological value.

We now come to the second category of my opponents, to those who have investigated the question of uterine disease, armed with the same means of physical examination as myself and my predecessors; and whose testimony is of a mixed character, corroborating some of the results at which we have arrived, and invalidating others; but who finally announce totally different conclusions. Foremost amongst these more formidable antagonists is Dr. West, to whose lectures I have just alluded. Before proceeding, however, I must be allowed to pay a tribute to the scientific spirit in which Dr. West's researches have been conducted, and to express my regret that I cannot reply to his objections, and at the same time extend to him the courtesy which he appears to have shown to me in not alluding to my name, although combating many of my opinions and assertions.

Dr. West's lectures are founded, as I havé stated, on the instrumental examination of 268 females, presenting uterine symptoms of sufficient importance in his eyes to warrant such an investigation. The lectures are written with a view to elucidate the pathological importance of ulceration of the uterine neck. In 125 cases, he found ulceration slight, or the reverse; in 143, there was no ulceration. Of the 143 cases in which no ulceration existed, in 29, the uterus was apparently healthy; in 110, it was not healthy in one respect or other. In the 110 cases of unhealthy uterus, the morbid conditions were either

displacements, enlargements, indurations of the body or cervix of the uterus, or congestion of the cervix: all more or less variously combined. These varied morbid changes and conditions, it should be remembered, are generally the result of acute or chronic inflammatory action, existing in the mucous membrane, or in the proper tissue of the neck or body of the uterus.

Dr. West's deductions and conclusions are principally drawn from the comparison of these two groups of females: those who present symptoms of uterine ailment with ulceration, and those who present the same symptoms without ulceration; and the pith of these deductions may be said to be, that as the symptoms and morbid results are nearly the same in both groups, ulceration can have no decided pathological importance, and is not a condition that requires special attention or treatment.

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I would, firstly, draw attention to the important corroborative testimony given by Dr. West as to the correctness of my statements respecting the frequency of inflammatory ulceration of the cervix uteri. Dr. West does what I have constantly implored all who presume to give an opinion on the subject to do -he looks, he examines for himself; and what does he find? 125 cases of ulceration in 268 women examined. If we eliminate the cases of healthy uterus, we find the proportions as follows:-Ulcerated, 125; non-ulcerated, 110; that is, more than half the patients examined presented ulceration. the 300 cases examined by myself at the Western General Dispensary, and reported in my work, the proportions were:— Ulcerated, 222; non-ulcerated, 78; that is, not quite threefourths presented ulceration. The difference between more than half and less than three-fourths is not one which, in a statistical inquiry of this nature, invalidates results. Dr. West's figures prove the extreme frequency of ulceration in women suffering from symptoms of uterine ailment just as forcibly as mine. The slight discrepancy would admit of easy interpretation were it desirable to enter into the subject. Amongst other causes, it may depend on the less degree of severity with which symptoms were scanned and weighed, before an instrumental examination was decided on.

What more conclusive answer than the above facts can be

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