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that such leucorrhoeas are to be held as acute or chronic inflammations of the canal of the neck, and ought to be treated accordingly."

Although Dr. Meigs thus recognises the existence and frequency of inflammatory lesions of the cervix uteri, attributes due importance to them, and teaches that they are surgical conditions which must be discovered and treated by surgical means if we wish to cure the leucorrhoeal discharges, and the local and general disturbance which they occasion, he denies that the term ulcer or ulceration can be applied to them. The disagreement, however, is clearly one of words only; his book itself contains several very good coloured figures, which most graphically represent the different stages of inflammatory ulceration. With Dr. Meigs it is a mere fastidiousness of phraseology, which a little thought and the knowledge of the labours of others will no doubt modify. He is so convinced, indeed, of the frequency of these diseased conditions, of their importance, and of the necessity of their surgical treatment, that he impresses most strenuously on all family practitioners, the necessity of becoming acquainted with the true pathology and treatment of these diseases, that they may afford real relief to their patients without the latter being obliged to apply to special practitioners.

Having thus established the soundness and correctness of the pathological facts on which the doctrines I advance are, in a great measure, founded, I shall briefly examine the various theories which are more or less current in uterine pathology, and which are invalidated by these doctrines. In speaking of Dr. West's researches, I have already referred to the views of those who, although admitting the existence of inflammatory lesions, most unaccountably and illogically deny their pathological importance. I shall now briefly examine various other opinions and doctrines, which I shall class under the following heads :-The Leucorrhoea Theory, the Syphilis Theory, the Ovarian Theory, and the Displacement Theory.





DR. TYLER SMITH's recent work appears to have been principally written in order to bring before the profession the peculiar views which he professes with reference to the morbid states, general and local, to which we have alluded as characterizing conditions of uterine ailment. The germ of these views is to be found in his Memoir of 1850. He therein observed, that the abrasions, granular conditions, &c., which are found at the os uteri, are probably "the result of irritation, produced by secretions depraved by some change in the innervation or nutrition of the uterus.' "" This is the idea which Dr. Smith has developed, and on which he has based a theory of uterine pathology, in opposition to what he terms the "Inflammation Theory." Calling to his assistance the microscopical talents of Dr. Hassall and of Dr. Handfield Jones, he has submitted the mucous membrane of the vagina, cervix, and cervical canal, to a minute microscopical examination, and the results thus obtained are interesting. It would appear that the vaginal and cervical mucous membrane, which are covered with pavement epithelium scales, contain few, if any, mucous follicles. The mucous membrane of the cervical canal, on the contrary, which is covered with cylindrical epithelium scales, presents even more mucous follicles disseminated over its surface than was previously supposed. The drawings of this mucous membrane, and of its follicular structure, are very beautiful, and the

description of their structure and disposition given by Dr. Tyler Smith is more minute than that of any previous anatomist. Numerous as we thought them, it appears that they are even still more numerous, amounting to many thousands. Adopting the researches of M. Donné and of Dr. Whitehead, Dr. Tyler Smith draws attention to the fact, that the ropy, mucous secretion of these follicles is alkaline, and remains transparent in the cervical canal. On reaching the vagina, and meeting with the acid vaginal secretion, its albumen becomes coagulated, if not very abundant, and it is thus transformed into the white, creamy fluid therein found.

Starting from these anatomical and physiological considerations, and extending his former idea, Dr. Tyler Smith assumes (p. 80) that a morbidly-augmented secretion from the mucous glands of the cervical canal, occurring under the influence of general or local causes, is "the most essential part of the disorder," in women presenting symptoms of uterine ailment, and is the cause of the mucous membrane lesions, and of their sequelae, which are observed in practice. To this morbid condition, which he terms Leucorrhoea, Dr. Tyler Smith attributes the morbid changes which I and others have described as the evidence and result of inflammation—that is, congestion, erosion, well-marked ulceration, hypertrophy, induration, the functional derangements of the uterus, and the secondary sympathetic reactions which are observed in the cases presenting them. The word inflammation is so sedulously avoided, that a careful perusal of Dr. Tyler Smith's work leaves in the mind a doubt as to whether he admits its existence even as a secondary result of this mysterious entity, "Leucorrhoea." Thus, at page 85, we find the following paragraph:

"In maintaining the important part played by the cervical secretions in inducing morbid conditions of the os uteri, I do not wish to be understood as saying that they are the only causes of these conditions. What I contend for is, that in the majority of cases in which leucorrhoea is present, in combination with non-malignant disease of the os and cervix, the morbidly active condition of the cervical glands is the primary and essential disorder. Amongst the other causes of morbid change

in the os and cervix uteri, the varying vascular and mechanical conditions of these parts in menstruation, coitus, pregnancy, and parturition, must of course be enumerated. Eruptive conditions of the cutaneous covering of the os uteri, in the shape of aphtha, herpes, or eczema, form another class of cervical discharge. Vaginitis may also extend upwards, and involve the os and cervix."

In the above extract it will be observed that the morbidly increased cervical secretion is not given as the cause of inflammation, which secondarily induces ulceration, induration, &c., but as the essential disorder of which these lesions are the morbid conditions. Neither is the intervention of inflammation recognised in the enumeration of the other causes which produce morbid changes in the os and cervix, except in the case of vaginitis extending to the cervix.

Dr. Tyler Smith seems to have endeavoured to establish an union between the pathology of former days and the results of modern experience. Thus formerly it was thought that the discharges, be they mucous, purulent, or bloody, which issued from the female organs, were in a great measure the mere reflex of general and functional morbid conditions. The modes of investigation which are now adopted show the all but constant existence, in such cases, of local lesions. Dr. Smith evidently tries to combine the two by thus stating that, under the influence of both general and local causes, the cervical secretions become morbidly exaggerated and modified, without the intervention of inflammation, thus establishing what he terms Leucorrhoea. This new entity, this peculiar morbid state once admitted, it becomes the source of all evil, producing congestion, erosion, ulceration, hypertrophy, abortions, sterility—indeed, whatever mischief subsequently occurs, local or general, in the uterine organs! Thus it is that we find him describing erosions, ulcerations, &c., not as inflammatory lesions, but merely as symptoms of leucorrhoea.

This attempt to unite past and present pathology does not certainly appear to me calculated to overturn what Dr. Smith calls "The inflammation Theory." What are the lesions described in the extracts I have given the congestions of the capillary

villi or network, the subsequent erosions, ulcerations, and hypertrophies? Are they not inflammatory lesions? To say that they are symptoms of leucorrhoea is merely to evade the question, to answer by a word which thus used has no rational meaning; and yet if Dr. Smith admits that they are in their intimate essence inflammatory conditions, why does he not frankly say so? In every part of the economy, in every tissue, they are considered by pathologists to be the symptoms, conditions, and sequelæ of inflammation, and to ignore this fact is to ignore the established laws of general pathology. Indeed, it would be just as rational to call inflammation, ulceration, and thickening of the mucous membrane of the throat, “leucorrhoea," as to give that appellation to these identical changes in the cervical and vaginal mucous membrane.

The unsoundness of Dr. Tyler Smith's fundamental doctrine is at once detected if we refer to the laws of general pathology. Mere morbid hypersecretions, fluxes, as they have been called, from mucous or glandular organs, do not produce irritation and morbid changes in the structures with which they come in contact, apart from inflammation. It requires the existence of inflammation to endow these hypersecretions with acrid irritating properties. Thus a mucous flux or discharge may exist from the bowels for months or years to an enormous extent, without the anus or adjacent parts ever being irritated. The nasal secretion may be greatly increased, for a considerable space of time, without irritation of the alæ of the nose or of the lips. But let inflammation be the cause of the hypersecretion or flux, and at once the scene changes. If the mucus from the bowels is occasioned by inflammation of the intestinal mucous membrane, it becomes irritating, and excoriates the anus. If the hypersecretion from the nasal mucous membrane is occasioned by coryza or inflammatory cold in the head, the alæ of the nose and the lips are excoriated. Moreover, in all these instances, the morbid changes themselves produced on the anus, the lips, the cheeks — erythema, excoriation, &c., are inflammatory changes, produced by an acrid inflammatory secretion. Inflammation has supervened both as

cause and as effect.

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