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made to Dr. Robert Lee, when he states that he has never seen an inflammatory ulceration of the uterine neck? Surely I need not pursue any further the refutation of this remarkable

assertion.

The frequency of inflammatory ulceration of the uterine neck is corroborated by several striking and important facts mentioned by Dr. West, as brought to light in the course of his inquiry, although, singularly enough, he does not appear himself to see that such is the necessary inference. Thus he examined 40 females affected with venereal diseases on the day of their admission into the venereal wards of St. Bartholomew's Hospital: 18 were suffering from gonorrhoea alone; 10 from gonorrhoea and syphilis; and 12 from syphilis only. Of these 40 patients, thirteen presented ulceration; " in 10 it was mere excoriation; in 3 the ulceration was more extensive."

Dr. West draws also from the above facts the conclusion that "be the causes of ulceration of the os uteri what they may, sexual excesses, at any rate, have no great share in their production." Now it appears to me that when, out of forty women possibly, not certainly, exposed to this influence, onethird (13 in 40) present ulcerative lesions in a more or less marked degree, and that the presence of these ulcerative lesions is not satisfactorily explained by the existence of syphilis, or by that of gonorrhoea, we are quite warranted in coming to a totally different conclusion. I would remind my readers, that the periodical examinations made by the Parisian medical police have proved the frequency of inflammatory lesions of the cervix uteri amongst the females most exposed to such

excesses.

Again, Dr. West gives the result of a careful examination of the uteri of 62 females who died in the medical wards of St. Bartholomew's Hospital of other than uterine disease. Of the whole number, 43 were married, or were presumed to be so; and 19 were believed to be virgins. The uterus was healthy in 33, diseased in 29. Of the latter, there was ulceration in 17; induration of walls of uterus without ulceration, in 5; disease of lining of uterus without ulceration, in 7.

Dr. West sees in this startling and very unexpected result

of his post-mortem researches, evidence of the non-importance of these lesions in a pathological sense! "The very frequency of their occurrence," he remarks (p. 26), " instead of substantiating the opinion that they are of great importance, rather militates against that supposition." I, on the contrary, see in it positive proof of what I have often stated-viz., that the existence, unrecognised and untreated, of a large amount of uterine disease in the female population, is an indirect cause of death. Inflammatory diseases of the uterus and of its neck are essentially debilitating affections, through their reactions on the functions of digestion and nutrition. When, therefore, as so generally occurs, they are not treated, they gradually induce. a state of debility and anæmia, and of deficient vital energy, which may render the female unable to resist the attack of intercurrent disease, to which she becomes an easy prey. at least is my interpretation of this pathological revelation.

Such

Whether pathologically important or not, the facts brought forward by Dr. West remain. Out of 62 miscellaneous uteri examined by him, there were inflammatory lesions, more or less severe, in 29, nearly one half, and in 17 there was ulceration. Thus does Dr. West himself blow to the winds and utterly destroy the value of the statistical statements made by Dr. Robert Lee, in the paper I have already quoted. According to Dr. Lee (p. 273), Dr. Boyd examined 708 uteri, at the Marylebone Infirmary, without finding a single case of inflammatory ulceration. He found 21 cases of cancer, 31 of bony or fibrous tumour, 13 dropsies of the ovaries, 24 puerperal cases, 3 of enlargement, but nothing else. Therefore, Dr. Boyd concludes "that ulceration of the neck of the womb is an exceedingly rare disease, else," he observes, "I must have observed it; having cut up and weighed many hundred (uteri), it could have scarcely escaped my notice.” Dr. Lee adds (p. 274), that Mr. Hewett and Mr. Pollock have examined 900 uteri at St. George's Hospital, and that they " did not observe a single example of simple ulceration of the os and cervix in the 900 uteri they examined, which confirms the accuracy of the opinion given by Dr. Boyd -that ulceration of the neck or mouth of the womb is a very rare disease."

At the time these statements were first published, and were brought forward as a proof that pathological anatomy gave no evidence even of the existence of a morbid condition said by me to be of such frequent occurrence during life, my reply was: that mucous membrane lesions had not been found after death, because they had not been sought for; as had often before been the case in the history of pathological anatomy. The observers whose results were so confidently appealed to by Dr. Leeobservers whose talents and integrity I esteem greatly-were looking for bony and fibrous tumours for dropsies and cancerous degenerescence—and they found them. They were not looking for inflammatory ulcerations, and they did not find them. I could bring other valuable testimony forward to corroborate the results arrived at by Dr. West, who being alive to the existence of ulceration, was looking for it and found it; but I prefer leaving to him, for the present, the refutation of Dr. Lee on this point, as on others. Certainly no one will accuse Dr. West of a favourable bias towards the views I defend.

I must, however, be allowed to call attention to the rather remarkable fact, that Dr. Lee comes to the conclusion that ulceration of the neck of the uterus does not exist and is of no pathological importance, because he does not find it after death; whilst Dr. West also concludes that it is of no pathological importance, because, on the contrary, he does find it very frequently after death.

DR. WEST'S DENIAL OF THE PATHOLOGICAL IMPORTANCE OF INFLAMMATORY ULCERATION OF THE NECK OF THE UTERUS.

In the preceding remarks, my principal object has been to show, that the researches of one of my scientific opponents, Dr. West, so far from invalidating the statements I have published respecting the frequency of inflammatory ulceration of the neck of the uterus during life and after death, powerfully confirm them, and constitute the best refutation I can adduce (apart from my own personal experience) of the negative assertions of Dr. Robert Lee. It now behoves me to analyse more fully the train of erroneous reasoning which has led so con

scientious and accurate an observer as Dr. West to differ entirely with me, and with those who adopt the same views as myself, as to the pathological importance of the lesions we both recognise.

The key to Dr. West's lectures, the explanation of the frame of mind under the influence of which his researches were carried out, and the résumé of the results to which they have led him, are to be found in a paragraph at the foot of page 14, which runs as follows: The really important question is, whether ulceration of the os uteri is to be regarded as the first in a train of processes which are the direct or indirect occasion of by far the greater number of the ailments of the generative system; or whether, on the other hand, it is to be considered as a condition of slight pathological importance, and of small semeiological value-a casual concomitant, perhaps, of many disorders of the womb, but of itself giving rise to few symptoms, and rarely calling for special treatment ?" The first part of this paragraph may be considered a concise statement of

the views Dr. West attributes to his antagonists, of the scientific error he thinks he has to encounter. The second part may be considered a concise enunciation of the opinions with which he rises from the investigation.

Dr. West wrestles with an imaginary enemy-combats a foe of his own creation. No pathologist, to my knowledge, as I have already stated, at home or abroad, has described ulceration of the os uteri as a morbid entity-as a disease existing per se. On the contrary, all who have written on the subject have spoken of ulceration, and described it as a result of the inflammation which invariably, necessarily, precedes and accompanies it, and which may exist without it for years, in the uterus as elsewhere. Dr. West has been apparently misled by the discussion to which Dr. Lee's extraordinary assertions gave rise. Dr. Lee, in his anxiety to crush the modern views of uterine pathology, boldly denied the existence of ulceration. He thereby thought to destroy doctrines which announced inflammation and inflammatory lesions as of constant occurrence, and ulceration as the most frequent secondary lesion of all, and the one that more especially necessitates instrumental

interference. Thence it was that the discussion took place on this one point: is there, or is there not, such a condition as ulceration? Thence also, I presume, the origin of Dr. West's error in thinking that his antagonists impute to ulceration alone all the pathological influences which they ascribe in reality to inflammation and to inflammatory lesions generally. At least, I can most assuredly say, that I have never in my writings for a moment attempted such a separation. This is evident from the very title of my work, which I call “A Practical Treatise on Inflammation of the Uterus, its Neck, and Appendages." If Dr. West will substitute, in the paragraph I have quoted, the words "inflammation of the neck and body of the uterus and their sequela," for the words "ulceration of the os uteri"-I will accept his proposition as a true exposition of my opinions; but as long as it remains as it is, I cannot possibly thus accept it.

This fundamental error, made at the very threshold of Dr. West's inquiry, appears to me to thoroughly negative its value. It has induced him to establish a comparison, which runs throughout his essay, and on which his statistical tables are based, between two groups of patients who, in reality, do not admit of being compared. This is at once apparent when we reflect that one group contains 125 females presenting inflammatory ulceration of the cervix, and the other group 110, who present morbid uterine conditions, by far the greater part of which are also the result of inflammation. Thus, the uterus was displaced in 36 cases; in 28 it was lower than natural; in 3 it was retroverted; in 5 anteverted; the body was enlarged in 20; the os or cervix was also enlarged or indurated in 10; the cervix or os was enlarged or indurated in 44; the orifice of the os was more or less congested, with the uterus healthy, enlarged, or misplaced, or with the os or cervix indurated in 58.

I cannot myself see what scientific advantage can possibly accrue from the minute comparison of the symptoms, local and general, presented by 125 women having ulcerated uteri; and by 110 women in whom the cervix uteri is not ulcerated, it is true, but who are mostly suffering from other modes of manifestation of the same inflammatory disease. It can only make

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