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tals, establishes in the most peremptory and undeniable manner, the oft-disputed accuracy of my pathological statements respecting the existence and frequency in the living and in the dead, of inflammatory lesions of the cervix uteri; such as ulcerations, indurations, &c. This testimony, therefore, utterly invalidates and destroys, were it still necessary, the scientific value of Dr. Robert Lee's negation of the existence of inflammatory ulcerative disease in this region of the body.

Secondly, Dr. West's negative conclusions as to the pathological importance of inflammatory ulceration of the os uteri, are, even in argument, quite valueless, owing to the singular fact of his having drawn them from the statistical comparison of two groups of patients, labouring, in a great measure, under identically the same disease, only manifesting its existence in one group by one mode of expression, in the other group by another mode of expression.


In the preceding remarks I have shown the utter fallacy of Dr. Robert Lee's denial of the existence of inflammatory ulceration of the neck of the uterus, by referring to the testimony of Dr. West, of St. Bartholomew's Hospital. Thus, on the authority of Dr. West, it is evident that when Dr. Lee writes-" 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" ("Medico-Chirurgical Transactions,” vol. xxxiii. p. 275) he must either have taken upon himself to contradict my statements without due investigation of the subject, or his mental vision must have been so obscured by prejudice, that he was incapable of recognising the truth when placed before him.

That Dr. Robert Lee is open to one or other of these imputations, is also undeniably proved by the recent evidence of Dr. Tyler Smith in his work on Leucorrhoea. Dr. Tyler Smith's testimony as to the existence of non-specific ulcerations of the cervix uteri, and consequently as to the soundness and correctness of the descriptions of the more severe forms of inflammatory ulceration, contained in the successive editions of my work

on Uterine Inflammation, is even more emphatic and more conclusive than that of Dr. West, inasmuch as it is based on minute microscopical investigation. It also carries with it the additional weight of emanating from a physician who, only a few years ago, publicly advocated and supported many of Dr. Lee's assertions.

Dr. Tyler Smith's first contribution to uterine pathology was a memoir, which was read at the Westminster Medical Society, and subsequently published in The Lancet, April 20th, 1850, under the title of "Observations on the supposed Frequency of Ulceration of the Os and Cervix Uteri." In this essay, Dr. Smith supported most of the opinions and views contained in Dr. Lee's memoir, although in a much more guarded manner. Thus he admitted the frequent existence of abrasions and excoriations of the cervix uteri, but denied their ulcerative nature, or their claim to be called forms of ulceration. Then, without denying, as Dr. Lee did, the existence of inflammatory ulcerations of the cervix uteri of a more marked type, he argued against their existence, both in the living and the dead, using the same arguments as Dr. Lee with reference to the living, and appealing to the same negative testimony-that of the curators of St. George's Hospital-with reference to the dead.

In order to show that I am not misrepresenting the views brought forward by Dr. Tyler Smith in the essay to which I allude, I must be allowed to give the following extract (The Lancet, vol. i. 1850, p. 474):—

"The granulations which are sometimes found surrounding the os uteri-which may secrete mucus or pus abundantly, and which may bleed on being roughly handled-are, I have no doubt, the result of inflammation; but they resemble the granular state of the conjunctiva, (Dr. Tyler Smith's italics,) rather than the granulations of a true ulcer, the granular os uteri offering no edges or signs of solution of continuity, by which we might satisfactorily declare it to be an ulcer. The granular os uteri would be a more correct designation, in such cases, than 'ulceration' of the os uteri. Some of the so-called ulcerations appear to be nothing more than patches of thickened epithelium, or portions of the os and cervix from which

the epithelium has been melted away by acrid and irritating secretions. It appears to me that we can neither receive the existence of excoriation, or abrasion; of granulation or of fungous growths; the secretion of pus or muco-purulent matter; as affording undeniable evidence of the existence of ulceration' of the os and cervix uteri. We must try ulceration in this part of the body by the same test which we apply to ulcers in other parts of the economy. We must look for a solution of continuity, with a secreting surface, separated from the healthy structures, having defined edges, everted or inverted,for an ulcer, in fact, in the common pathological meaning of the term."

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Such were Dr. Tyler Smith's views of the pathology of ulceration of the uterine neck in 1850. Even after the elimination of abrasions and excoriations, the result of morbid action, not of accident, be it remembered,-Dr. Smith refused to admit that "bleeding granular surfaces, secreting mucus and pus abundantly," were ulcerations, because, apparently, they had not (like old skin ulcers) "defined edges, everted or inverted." The very enunciation of such views as the above impressed me at the time with the conviction that they originated in want of practical experience, and in the controversy which followed between myself and Dr. Smith I said as much. The following year Dr. Tyler Smith was appointed physician-accoucheur to St. Mary's Hospital, where a wide field of practical observation was opened to him. What has been the result? Dr. Smith has recently published a work on "Leucorrhoea," in which the granular, bleeding, muco-pus-secreting surfaces, described above as not constituting ulceration, as not deserving that appellation, are now carefully and minutely depicted as superficial ulcerations of the os and cervix uteri, and are distinctly stated to be the morbid change that immediately follows abrasions or excoriations of the mucous membrane (vide pp. 88, 89, 90). The following paragraphs are verbatim extracts from Dr. Smith's work :

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Epithelial Abrasion of the Os and Cervix Uteri.—The next morbid change (to vascular injection of the os and cervix uteri) consists of loss of epithelium, and partial or entire denudation


of the villi.

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To the naked eye a red circle of excoriation surrounds the os uteri. It sometimes involves the whole surface of the os uteri, and extends to the upper part of the vagina, and also ascends within the canal of the cervix. The denuded surface does not generally secrete pus, but an abundance of mucous plasma and epithelial scales is produced, and the surface frequently bleeds upon slight irritation. To the naked eye the abrasion appears rough, and to the touch it feels erectile and velvety'—a term which has very commonly been applied to what has been considered ulceration of the os and cervix uteri. The villi do indeed in this condition stand out somewhat like the pile of velvet, and in some cases the villi themselves are considerably enlarged. When such cases are examined microscopically after death, the villi are seen with their vascular loops, but with entire loss of their epithelial covering. The naked villi are sometimes so large as to be visible, and they look like an irregular fringe skirting the uterine aperture. This state has been considered one of superficial ulceration, but epithelial abrasion is the only morbid change which exists in cases of this kind, and it is nothing like that state which is considered ulceration in other parts of the body. If this were to be considered genuine ulceration, we must apply the same term to the simple loss of the epidermis after the application of a blister to the skin. In leucorrhoea, it is, I believe, caused, like the superficial redness, chiefly by the irritation of the os uteri from the alkaline cervical discharges. This loss of epithelium is the most frequent change which I have met with upon the surface of the os uteri in cases of ordinary leucorrhoea."-pp. 82, 83.

"Superficial Ulceration of the Os and Cervix Uteri.-When these changes have proceeded a step further, there is found not merely loss of the dense layer of epithelium covering the os uteri, but the villi both of the external surface of the os uteri, and of the mucous surface within the labia uteri, are destroyed entirely or in patches. It is this condition which constitutes the granular condition of the os uteri. In that state of the os uteri, which upon examination after death would be pronounced to be undoubtedly superficial ulceration, the condition

which generally obtains is a partial or entire loss of the epithelial layer around the os uteri in circumscribed patches, and here and there the partial or entire destruction of the villi. This loss of the villi gives an eaten, corroded appearance to the surface of the os. Such a condition of the os uteri may be limited in extent, or it may spread over the whole of the os uteri and external portion of the cervix, and pass within the labia. In this state there is a free secretion of purulent or muco-purulent fluid. . . . . On the surface of the os uteri superficial ulceration does not go beyond the removal of the epithelium and villi, but I have seen a portion of the rugæ in the lower part of the cervical canal itself eaten away in very severe cases."pp. 83, 84.

What can be more graphic, and at the same time more minute, more accurate, and more conclusive than this description of ulceration of the uterine neck? And yet it is from the pen of a pathologist, who, when he wrote the memoir from which is taken the first extract, considered these identical mucous membrane lesions to be merely granular, conjunctivalike states, of a non-ulcerative nature. It is from the pen of one who, if he did not repudiate the very existence of ulceration in this region, like Dr. Lee, appeared to accept it principally on the faith of others, and more through cautious reserve than because he had ever himself met with any lesion of the kind.

At the time that Dr. Robert Lee's memoir and that of Dr. Tyler Smith were simultaneously brought forward, the one at the Medico-Chirurgical Society, and the other at the Westminster Society, the one denying the very existence of inflammatory ulceration of the uterine neck, and the other, if not its existence, its frequency-at the time that the archives of St. George's Hospital were ransacked for post-mortem arguments— it was currently reported that the result of this combined effort would be the annihilation of the views I upheld. The unsoundness of doctrines so pernicious in their tendency, it was said, was to be demonstrated, their progress arrested, and those who supported them placed under general professional ban. I must be pardoned if I here briefly state what has been the result of

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