Such being the pathological law in other parts of the economy, it must also hold good in the uterus. The morbid hypersecretions of the cervical canal, and of the vagina, are in themselves innocuous, and only acquire irritating properties through the intervention of inflammation. They may and do increase and diminish in the different phases of the female's physiological state, under the influence of menstruation, pregnancy, over-exertion, mental emotion, &c., without any local morbid change occurring. This, indeed, Dr. Tyler Smith himself acknowledges and developes. When, however, their increase is accompanied with the ordinary local evidences of inflammation-swelling, redness, heat, pain, ulceration, and thickening of diseased tissues-it is because inflammation co-exists, here as elsewhere, has changed the character of the discharge, and developed the whole train of morbid changes that characterize inflammation, &c. To say that the primary cause of these morbid conditions, the essential disorder, is the morbidly increased mucous secretion, is a mere assertion which cannot be proved; and is contrary, as we have seen, to the laws of general pathology, our only safe guide in such questions.

This doctrine of "leucorrhoea," as developed by Dr. Tyler Smith, appears to me a mystical, unpathological doctrine, unworthy of the present state of science. It is a doctrine that substitutes words for facts. What, I would ask, is the intimate nature, the cause of this morbid hypersecretion which, according to his views, is the "essential disorder;" which creates morbid changes that are not inflammatory, although they present all the characteristics of inflammatory lesions? Dr. Tyler Smith cannot tell us, for he ignores inflammation, and does not soar above the idea or a "morbidly exaggerated secretion." But the profession will tell him that the essential disorder is inflammation-neither more nor less.

Much might be added, but I believe I have said enough to show that the new "Leucorrhoea" theory is but a poor substitute for the one Dr. Tyler Smith attacks. This, the "inflammation theory," as he calls it, is founded on the recognition of the positive fact, that most of the morbid lesions observed in patients suffering from confirmed uterine ailment are inflam

matory lesions, the result of inflammation. Those who adopt it believe that, in these cases, inflammation is the primary condition, as in other mucous membranes, and that the hypersecretions are, generally speaking, quite secondary, mere symptoms. At the same time, we believe that the inflammatory disease itself, and the lesions it produces, including the hypersecretions, are completely subservient to the general pathological laws which regulate inflammation in its origin, progress, and termination, in all parts of the animal economy.

Before I pass to another subject, I would remark, that Dr. Smith, throughout his work, corroborates a very important practical fact, which I was, I believe, the first to point out and elucidate―viz., that the discharges, mucous or purulent, which issue from the cervical canal are generally secreted by the cervical canal, and not by the uterine cavity. In other words, I believe that I was the first to demonstrate that nearly all that had been previously written by French and English pathologists on endo-metritis, or inflammation of the lining membrane of the uterine cavity, had been written in error as to the seat of disease, and as to the origin of the morbid discharges. Instead of proceeding from the uterine cavity, as was generally supposed, in the great majority of cases, they proceed from the cervical cavity or canal only, the uterine mucous membrane being, comparatively, seldom the seat of disease and of morbid secretions. These views were developed at great length in the second edition of my work on "Uterine Inflammations," 1849; and it is gratifying to me to find them so thoroughly corroborated by Dr. Tyler Smith's more recent researches.

Recognising, as Dr. Tyler Smith does, fully, the pathological importance of uterine lesions, ulcerative and other, he agrees with me as to the absolute necessity of their removal by local as well as by general treatment. He adopts the more simple means of local treatment which I recommend-astringents, injections, local depletion, applications of the nitrate of silver, &c., but repudiates and strongly condemns the more energetic surgical agencies, such as the acid nitrate of mercury, and other mineral acids, potassa fusa, the actual cautery, &c. Dr. Tyler Smith must not think me discourteous if I once more appeal to time

and to his own increased experience. These will, in my opinion, inevitably do away with all disagreement between us, by proving to him the absolute necessity of the more potent surgical agencies which he now repudiates. Dr. Tyler Smith is too sensible a man, too clever a physician, to leave in the hands of his fellow-practitioners means of treatment which are occasionally indispensable in order to entirely remove important morbid conditions. When additional experience has shown him that there are patients, especially in private practice, where cases can be followed, who can only be restored to health by the instrumentality of the vitality-modifying agents which he now condemns; and that if he does not therewith cure them, others will; I predict that he will pass the "Rubicon," and become a convert to the vitality-modifying doctrine, as he has become a convert to the ulcerative doctrine.

Should that day come, however, as I believe it will, I shall have a right to ask Dr. Tyler Smith to publicly acknowledge his conversion, and not in a second or third edition of his work, to act by this question, as he has done in the first by the ulceration one. Although compromised, as we have seen, by the expression of very decided opinions, in the controversy on the existence and frequency of ulceration of the neck of the uterus, Dr. Smith, in his work on Leucorrhoea, never even alludes to his having formerly entertained other opinions than those which he enumerates; but quietly describes ulceration as if its pathology had never been questioned, either by himself or by any one else. I may be allowed to add, that many practitioners who formerly denounced me loudly for using too energetic surgical means in the treatment of uterine disease, have, since then, taught by experience and by my example, adopted these very means, and are now quietly and tacitly employing them, thereby gaining credit and honour in practice. Such a course may be admissible in a private practitioner, but it is certainly not justifiable in a public man, in one who claims to teach and to lead professional opinion.

The term leucorrhoea, if retained at all, ought, in sound pathology, it appears to me, to be reserved for those forms of passive mucous hypersecretion of the vaginal, cervical, and intra

cervical mucous membrane which often temporarily exist independently of inflammatory lesions, and independently of uterine ailment. These passive and fleeting conditions of hypersecretion, really and truly, are the reflex of general conditions of health, and seldom come under the eye of the profession as distinct morbid states.

THE SYPHILIS THEORY.

One of the first explanations that were given in Paris, many years ago, of the presence of inflammatory and ulcerative lesions of the uterine neck, was, that they were frequently, if not principally, secondary syphilitic conditions. This explanation of no longer deniable pathological facts has found, of late, advocates and supporters in England. Amongst others, I may mention Dr. Tyler Smith, who, in his work "On Leucorrhoea," states "that far too little importance has hitherto been given to the connexion between Secondary Syphilis and obstinate Leucorrhoea with disease of the os and cervix uteri," (p. 96.) A few pages further on, after discussing my opinions on the subject, he adds, “I have always been of opinion that there is a large amount of undetected syphilis in the works of Dr. Whitehead and Dr. Bennet."

The careful perusal of the arguments brought forward by Dr. Tyler Smith and others has not, however, in any respect modified the opinions which I laid before the profession in 1845, in the first edition of my work on "Uterine Inflammation." My firm impression, indeed, is, that Dr. Tyler Smith, and those who formerly defended, or now defend, similar ideas, very greatly exaggerate the part that syphilis, primary or secondary, plays in the production of inflammatory lesions of the neck of the uterus. Their view of the subject appears to be the natural result of a transition state of opinion. First, inflammatory lesions of the uterine neck are ignored or denied. Second, it being no longer possible to deny their existence, they are considered to be often syphilitic. Third, their inflammatory nature is recognised as the rule, and their syphilitic nature is taught to be an occasional but rare occurrence. May I be allowed to add, that I have a strong conviction, that when the pathologists who

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now see syphilis everywhere have had as much experience of local uterine disease as I have had, their ideas will undergo considerable modification.

The opinions which I hold on this subject have not been adopted without considerable study, experience, and research. In the year 1840, I became attached as interne (house-surgeon) to the Hôpital St. Louis, the celebrated Parisian Skin Hospital, to which are sent most of the cases of secondary syphilis that apply for admission to the Bureau Central. I was then told by several of the medical officers that ulcerative affections of the neck of the uterus were very common amongst these patients, and that they were considered to be mostly of a secondary syphilitic character.

I remained at this hospital two years, and during nearly the entire time I had under my charge several wards of women suffering under secondary cutaneous syphilis. I invariably examined the state of the uterine organs, and found, as I had been told, that ulcerative lesions of the uterine neck were of very common occurrence. At first, I was quite prepared to accept their secondary nature; indeed, I may say that the bias in my mind was such as would have naturally led me to this conclusion. But before I came to St. Louis I had had much experience of uterine disease in non-syphilitic hospitals, and especially at La Pitié, where vast numbers of females are received who have recently left the Maternité, the largest lying-in hospital in Paris, and in whom the uterine lesions are undeniably of an inflammatory nature. Thus forewarned, I was at once struck by the similarity between the ulcerative states I saw amongst the syphilitic patients at St. Louis and the ulcerative states I had seen amongst the non-syphilitic patients at La Pitié. This induced me to question the secondary nature of the uterine disease in the former, and to investigate narrowly the entire subject.

The researches which I then commenced were carried on throughout my lengthened residence in this hospital, and soon showed me that not only the morbid characters presented by the ulcerations were, generally speaking, quite different from those which are observed in the throat in secondary syphilitic