CHAPTER XIII.

Fig. 98.—Left lateral laceration of the cervix with erosion.

Fig. 99.—Stellate laceration of the cervix.

An incomplete laceration of the cervix is sometimes found. In this injury the tear has extended but part way through the wall of the cervix. The mucous membraneof the cervical canal and the muscular wall of the cervix are lacerated, but the injury does not involve the mucous membrane of the vaginal aspect, beyond, perhaps, a slight splitting of the external os (Fig. 100). The lesion is thus concealed, and separation of the portions of the cervix is prevented. The injury may be detected by introducing a sound in the cervical canal and placing a finger on the vaginal aspect of the cervix, when it will be found that at this spot the point of the sound and the finger are separated only by the thickness of the vaginal mucous membrane, and not by the normal thickness of the wall of the cervix.

Fig. 100.—Incomplete laceration of the cervix.

The appearance of a lacerated cervix varies with the time that has elapsed since the receipt of the injury. A few weeks or months after the occurrence the torn portions of the cervix will be found, by sight or touch, lying in more or less close apposition, the general conical shape of the cervix being unaltered. After the lapse of a longer period, however, the edges of the laceration become rounded, and a certain amount of eversion, or turning out, of the portions of the cervix takes place, so that the mucous membrane of the cervical canal becomes exposed. This eversion is always most pronounced in the bilateral laceration, and is especially striking when the tear has extended entirely through the cervix into the lateralvaginal fornices. In such cases the cervix assumes the shape of a split stalk of celery (Fig. 101). The cases of laceration with eversion of the lips are those in which the most marked symptoms are found. When eversion occurs, and the mucous membrane of the cervical canal is exposed, the shape and appearance of the cervix are very much altered from the normal. Before the true nature of this lesion had been pointed out by Emmet such a cervix was said to be ulcerated, the raw-looking surface, corresponding to the exposed, irritated, and inflamed mucous membrane of the cervical canal, having been mistaken for an ulcer. Even at the present day such a mistake is not infrequently made.

Fig. 101.-Bilateral laceration of the cervix with eversion. The dotted line shows the normal shape of the cervix.

Microscopical examination of such raw-looking surfaces shows that they are in no sense ulcers. “The surface is covered with a single layer of epithelium; the cells are smaller than those which line the normal cervical canal, and, being narrow and long, have a palisade-like arrangement; the thin layer of cells allows the subjacent vascular tissue to shine through, hence the redness of color. The surface is further thrown into numerous folds, producing glandular recesses and processes; these processes cause the granular appearance of the surface” (Hart and Barbour).

These red patches are larger than the surface of the everted mucous membrane of the cervical canal; they are continuous with, but extend beyond the limits of, this mucous membrane. It is said that this increase is occasionedby proliferation of the epithelium that lines the cervical glands.

As a substitute for the misleading term “ulceration,” applied to this condition, there have been proposed the terms “erosion,” “ectropion,” or “eversion” of the mucous membrane, and “catarrhal patch.”

A true ulcerated surface is sometimes found on a lacerated cervix as a result of excessive irritation, but such a condition is rare.

As the laceration occurs in the cervix before involution has begun, this process is impeded, so that a state of subinvolution of the cervix results, and the part remains hypertrophied or much larger than normal.

The cervical glands share in this condition of subinvolution, retaining much of the increased size and activity that are normal in the pregnant state.

Changes due to chronic congestion and inflammation also take place. The connective tissue increases in amount, and the cervix becomes hard, indurated, or sclerotic.

The racemose glands, which open upon the cervical mucous membrane, become inflamed, and, as a result of change in the consistency of the glandular secretion or of obstruction of the gland-orifices, retention takes place, with the production of small cysts called Nabothian cysts. Such cysts often extend peripherally, so that the distal end of the occluded gland approaches the vaginal aspect of the cervix, and appears beneath the mucous membrane as a translucent vesicle about the size of a small pea. Puncture of such a vesicle permits the escape of a drop of gelatinous fluid.

The whole of the body of the cervix may be filled with innumerable cysts of this kind, of varying size. When projecting beneath the mucous membrane they feel like small shot imbedded in the cervix. A cervix in this condition is said to have undergone cystic degeneration. The inflammation of the lower exposed portion of the mucous membrane of the cervical canal extends upward,so that a condition of general chronic cervical catarrh results. This exceedingly common disease is usually caused by laceration of the cervix.

The focus of continuous irritation in the cervix interferes with the normal involution of the body of the uterus, so that there occurs a condition of uterine subinvolution, which may be the cause of the chief symptoms with which the woman suffers. The endometrium shares in the subinvolution, and, as a consequence of this, and perhaps also from extension of inflammation from the cervical mucous membrane, various forms of endometritis may occur.

In some cases of laceration of the cervix no groove corresponding to the angle of the laceration can be felt or seen, because it has been filled with a plug or mass of cicatricial tissue. In such cases this plug of scar-tissue may be felt, distinguished by the palpating finger from the softer surrounding tissues of the cervix.

Symptoms.—The symptoms of laceration of the cervix uteri are usually referable to pathological conditions that are secondary to the laceration, and are in no way characteristic. Leucorrhea, or a discharge from the exposed and inflamed cervical mucous membrane, is usually present. Menstruation is often irregular, and is increased in duration and amount as a result of the subinvolution of the uterus and the chronic congestion, and perhaps inflammation, of the endometrium. Backache and vertical headache may also be present from the same cause.

If the tear is at all extensive—and especially if it extends through the cervix into the cellular tissue of the broad ligament—pelvic pain, referred to the general position of the scar, may be experienced.

Movement of the cervix or of the uterus that causes traction upon the scar in the broad ligament produces pain. Such pain may result from the bimanual examination, from jarring or movements of the body, from defecation, or from coitus.

Much of the pelvic pain with which women suffer inlaceration of the cervix is probably due to the pelvic lymphangitis and lymphadenitis that are caused by the continuous irritation of the diseased cervix.

Sterility is a not unusual accompaniment of laceration of the cervix. It may be due to the malposition of the external os or to the profuse cervical discharges. In case conception occurs, abortion may follow on account of the pathological condition of the body of the uterus and of the endometrium.

Sometimes very marked reflex nervous disturbances are caused by a laceration of the cervix. Such disturbances are most pronounced in those cases in which there is much cicatricial tissue, and in those in which the cervix is hard and sclerotic or cystic as a result of long-standing inflammation—in other words, in those cases in which the substance of the cervix is most affected.

Neuralgia may occur in any part of the body. It is usually situated in the pelvis, or it may extend to the groin and down the thigh. Reflex nausea and vomiting may result from this as from other lesions of the uterus. Cataleptic convulsions and neurasthenia may also result from an old laceration of the cervix. The pelvic focus of irritation is constantly wearing and exhausting nervous energy.

Diagnosis.—The diagnosis of laceration of the cervix is readily made by digital examination. The palpating finger feels the one or more angles of laceration. The cervix loses its normal dome-like shape and becomes broader and flatter. In those cases of bilateral laceration where the eversion of the lips of the cervix is so marked that the angles of laceration are obliterated—becoming, in fact, 180 degrees—or where the angles have become filled up by a plug of cicatricial tissue, the angles of the laceration, of course, cannot be felt. We may often, however, detect the presence of the plug of cicatricial tissue, which feels harder than the surrounding tissues of the cervix; and we can always determine the presence of the eversion which seems to have obscured the lesion.As the finger is passed over the flattened presenting cervix it is found that the shape is not round, but oval, with the long axis antero-posterior. The finger passes around a corner or edge as it glides into the anterior or posterior vaginal fornix. This corner or edge is the extremity of the torn everted lip of the cervix. It corresponds approximately with the margin of the normal external os. The apparent external os, or the opening of the cervical canal, which occupies the center of the presenting cervix, is really a part of the cervical canal higher up than the normal os—a part of the canal that has been exposed by the laceration and separation of the lips. This fact should be remembered when the length of the uterus is measured by the sound. The measurement taken from the apparent external os is often half an inch, or even one inch, less than it would be if the cervix were restored. The degree of subinvolution of the uterus indicated by the measurement of the length is often, therefore, considerably greater than would be supposed after such imperfect measurement.

The presence of an erosion on the face of the cervix may also be determined by palpation. The eroded surface has a soft and somewhat velvety feeling, in contrast with the smooth surface of the normal vaginal cervix covered with squamous epithelium.

The cystic degeneration is readily detected by feeling the small shot-like cysts that cover the cervix; and the sclerotic condition is indicated by the increased hardness or induration, which is easily perceptible to the finger.

The most satisfactory visual examination of a lacerated cervix is made through the Sims speculum, with the woman in the Sims or the genu-pectoral position. The bivalve speculum, by separating the upper vaginal walls, often increases the eversion of the lips and masks the lesion.

The nature of the injury in cases of bilateral laceration with eversion may readily be proved in examining through the Sims speculum. If the anterior and posteriorlips of the cervix be seized with tenacula and then drawn together, it will be observed that the area of erosion disappears and the normal shape of the cervix is approximately restored.

Treatment.—All forms of laceration of the cervix in which there exist eversion, erosion, cystic degeneration, and sclerosis should be operated upon. A slight laceration in a young woman in the active childbearing period does not demand operative treatment if there are no symptoms referable to the laceration. In women approaching middle life (forty years of age) all lacerations of the cervix should be closed, whether or not they produce symptoms.

It should always be remembered that cancer is most likely to originate in a cervix that has been lacerated, and the woman should be protected against this danger.

The treatment of laceration of the cervix is operative. A definite mechanical injury has been inflicted, and the parts must be repaired by operation.

The operation for the repair of a lacerated cervix is called trachelorrhaphy. The operation consists in denuding or excising the tissues on the torn surfaces and bringing the freshened surfaces together with sutures.

The form of the operation for a bilateral laceration is shown inFig. 104. The operation should preferably be performed immediately after a menstrual period.

The instruments necessary for the operation of trachelorrhaphy are two double tenacula, two single tenacula, tissue-forceps, needle-holder, shot-compressor, Sims’ speculum, needles, (Fig. 102), knife, and scissors, sharp-pointed and curved on the flat (Fig. 103). The needles should be spear-pointed and should be strong and sharp, as the cervical tissues through which they are passed are often very dense. The straight or the curved needle may be used.

Fig. 102.—Cervix-needles.

Silkworm gut, shotted, is an exceedingly good suture-material.

The woman should be placed either in the Sims or the dorso-sacral position. The vulva, vagina, and cervix should be thoroughly cleansed and rendered as aseptic as possible. The cervix should be exposed through the Sims speculum. The anterior and, if desirable, the posterior lip of the cervix should be seized with a double tenaculum and held by an assistant; or the lip may be transfixed by a silk ligature, with which the cervix may be held.

Fig. 103.—Curved scissors for performing trachelorrhaphy.

The denudation, which may be made with a knife or with scissors curved on the flat, should be begun upon the lower lip. The tissue to be removed may first be marked out with the knife. The tissue to either side of the old external os is seized with a tenaculum or with toothed tissue-forceps, and a strip is elevated by an incision extending into the angle of the tear. A corresponding opposite portion of tissue on the anterior lip is then seized in a similar manner, and a similar strip of tissue is excised, meeting and joining the strip first raised in the angle of the tear. We thus remove a wedge-shaped portion of tissue. The operation is then repeated upon the other side. The strip of mucous membrane that is left on the center of the lips to form the new cervical canal should be about a quarter of an inch in width.

If the finger be passed over the freshened surfaces, small indurated masses of tissue are sometimes felt. Such tissue should be caught with the tenaculum or theforceps and excised. This condition is most usual when the tear has been of long standing and the cervix has undergone sclerotic changes. It is important that the excision of tissue should be carried well up in the angle of the laceration, in order that all hard cicatricial tissue may be excised.

The excision of tissue should be done as nearly as possible in the plane of the laceration. A frequent mistake is to remove too much tissue from the vaginal aspect of the cervix.

There is usually but little bleeding in the operation of trachelorrhaphy, and whatever bleeding there is may always be controlled by properly placed sutures.

The first suture should embrace the angle of the laceration. It should be introduced on the vaginal aspect of the cervix, near the edge of the mucous membrane, and should emerge on the edge of the mucous membrane of the cervical canal. It should then be reintroduced at a corresponding point on the opposite lip, and should emerge on the mucous membrane of the vaginal aspect. It is often difficult to bring the first suture out on the mucous membrane of the cervical canal. This, however, is not necessary if the suture embraces the whole of the denuded angle.

The other sutures, usually two or three in number, are introduced in a similar manner near the edge of the mucous membrane of the vaginal aspect, pass around the whole of the denuded surface, and emerge on the mucous membrane of the cervical canal, near the edge. They are then re-introduced on the opposite lip, and emerge at a corresponding point on the vaginal aspect of this lip.

A frequent mistake is to bring the sutures out on the raw surface so that the lateral union of the torn lips is shallow and superficial, often consisting only of the thickness of the mucous membrane of the vaginal aspect of the cervix. As the result of such an operation the new-formed cervical canal is spindle-shaped, much broaderthan normal, and the condition of an incomplete laceration of the cervix results.

Fig. 104.—Steps of the operation of trachelorrhaphy for bilateral laceration of the cervix uteri:A, bilateral laceration with erosion;B, the area to be denuded has been marked out with the knife;C, the denudation has been accomplished;D, sutures introduced;E, completed operation.

After the operation the vagina should be washed out with a 1:2000 solution of bichloride; it should then be dried with sponge or gauze, and a light vaginal pack of sterile gauze should be introduced.

The gauze pack should be removed at the end of forty-eight hours, and after this a daily douche, with subsequent drying of the vagina, should be administered. The woman should remain in bed for two weeks. There is always present some subinvolution of the uterus, which is much benefited by rest in the recumbent position.

The sutures may be removed at any time after two weeks. To do this the woman should be placed in the lithotomy position. The perineum should be retracted with a Sims speculum, and the anterior vaginal wall should be supported by an elevator in the hand of an assistant.

If a perineorrhaphy is necessary, it should be performed at the same time as the trachelorrhaphy. In this case the cervix sutures should not be removed for three or four weeks, in order to avoid pressure upon the perineum by the retracting speculum.

If there is present marked subinvolution of the uterus with accompanying endometritis, the cervical canal should be slightly dilated and the body of the uterus should be thoroughly curetted immediately before performing the trachelorrhaphy.

If the operation of trachelorrhaphy is performed within a few months after the receipt of the laceration—before sclerotic, cystic, and erosion changes have appeared—there is usually required but little preparatory treatment. When, however, there is a marked and widespread erosion, and the cervix is full of numerous Nabothian cysts, or is hard and sclerotic from inflammatory exudate, it is necessary to devote from two to six weeks to preparation of the cervix for operation. Many failures in the operation of trachelorrhaphy are due to neglect of such preparatorytreatment. The hard, cystic cervix may unite but imperfectly after operation, or the symptoms referable to the diseased cervix may remain unrelieved by the operation. We often see women in whom laceration of the cervix has been closed with good union, and yet the sclerotic cystic condition of the cervix, and perhaps subinvolution of the uterus, persist, and symptoms continue as pronounced as before operation.

The preliminary or preparatory treatment consists of the administration of vaginal douches, regulation of the bowels by saline purgatives, and local applications to, and puncture of, the cervix uteri.

The woman should take, two or three times a day, a vaginal douche of one gallon of hot water (110° F.). The douche should be administered in the recumbent posture.

One or two watery fecal movements should be produced daily by Rochelle salts, sulphate of magnesium, or some similar preparation.

Fig. 105.—Cotton tampon.

Every five or six days the woman should be placed in the knee-chest position and the cervix should be exposed with the Sims speculum. The Nabothian cysts, which appear as translucent vesicles beneath the mucous membrane, should each be punctured with a sharp knife-point. If the cervix is much enlarged and congested, it should be freely punctured over the whole vaginal aspect to produce local depletion. Half an ounce or an ounce of blood may be removed in this way. The cervix should then be thoroughly dried, and an application of Churchill’s tincture of iodine should be made over the whole of the cervix and the vaginalvault. The excess of iodine should be removed with a little cotton, and a cotton tampon (to which is attached a string) saturated with glycerin should be placed against the cervix (Fig. 105). The hygroscopic action of the glycerin is most useful in depleting the cervix. The woman should be told to remove the tampon by traction on the string at the end of twelve hours, and to follow the removal with a vaginal douche of hot water.

Such local treatment should be instituted immediately after a menstrual period and should be repeated every five or six days, and continued until the erosion and the cysts have disappeared and the induration has diminished. Three weeks of such treatment usually produce a very marked change. The cervix not only becomes much more healthy in appearance, but most of the symptoms of which the woman complained vanish. The leucorrhea diminishes or ceases; the backache and headache disappear. The relief is often so marked that the patient suggests the advisability of deferring operation. This, however, should never be countenanced, as all the symptoms will return with cessation of treatment.

If, after the careful administration of the treatment here prescribed for five or six weeks, the induration and cystic degeneration do not disappear, then the case is not one that will be benefited by trachelorrhaphy. The mere closure or union of the indurated and cystic lips of the cervix will not cure the woman if these conditions persist.

If the inflammatory changes secondary to the laceration have become so deeply seated that they are not relieved by the preparatory treatment, amputation of the cervix is necessary. In any doubtful case, therefore, this preparatory treatment is to a certain extent indicative of the character of the ultimate operation to be performed.

The description of the operation already given is applicable to the most usual form of laceration—a bilateral laceration. If the injury be unilateral, it may be necessary to split the cervix on the sound side in order to denude, and to introduce sutures, on the injured side. Thecase may then be repaired as in the bilateral form of injury. In the case of the unusual stellate laceration the lacerations must be separately repaired, or two lacerations may be converted into one by excision of the intervening tissue.

The incomplete laceration may be recognized in the manner already described, by introducing a sound into the cervical canal and a finger in the vaginal fornix. Such an injury should be treated by splitting up the cervix and converting the incomplete into a complete tear, and then denuding where necessary and closing as in the case of an open laceration.

If, in an old laceration, the sclerotic and cystic condition of the cervix does not yield to the preparatory treatment advised, amputation of the cervix is necessary.

Fig. 106.—An old incomplete laceration of the cervix with hypertrophy and cystic degeneration. Amputation is necessary.

Amputation of the Cervix.—This operation is performed as follows: The cervix is split bilaterally to the vaginal junction with knife or scissors. Two flaps are formed in this way, and each flap is then amputated separately, the posterior one first (Figs. 107-109). An incision is made on the vaginal aspect of the posterior flap, extending from the angle of the split on one side to the angle of that on the other. The knife is thrust deeply into the cervical tissue and is directed toward the cervical canal. An incision is then made across the mucous membrane of the cervical canal, on the anterior aspect of this flap. The posterior lip is thus removed. The anteriorlip is removed in a similar manner. The stump of the cervix is then closed by sutures. Two or three sutures are introduced on each side of the cervix to close the angles, just as in the operation of trachelorrhaphy for a bilateral tear, and two sutures are introduced on each flap to attach the mucous membrane of the cervical canal to the mucous membrane of the vaginal aspect, to form the new external os. The first sutures should be passed well up in the angles at the lateral vaginal fornices, to control bleeding. Bleeding is more likely to be free in this operation than in a simple trachelorrhaphy, but it may always be controlled by the proper application of the first sutures placed in the angles.

Fig. 107.—Operation of amputation of the cervix uteri:A, the cervix has been split laterally, forming an anterior and a posterior flap;B, the posterior flap has been partly amputated.

Fig. 108.—A, the posterior flap has been amputated;B, both flaps have been amputated.

Fig. 109.—A, the sutures have been introduced;B, completed operation.

The post-operative treatment is similar to that after the operation of trachelorrhaphy.

Amputation of the cervix does not interfere with conception, with the course of pregnancy, or with labor.

The mucous membrane of the cervical canal may be the seat of acute or chronic inflammation. Acute inflammation usually occurs as part of a general acute process affecting the whole of the endometrium, and is commonly the result of gonorrheal or septic infection. It will be considered under General Endometritis.

Chronic inflammation of the mucous membrane of the cervical canal (cervical catarrh or cervical endometritis) is an exceedingly common affection. Unless caused by gonorrhea, it is nearly always secondary to some local or general condition.

The pathological changes that take place in the mucous membrane resemble those found in a similar process in other parts of the body. There is a very marked congestion and hypersecretion of the racemose glands of the cervical canal, so that the most prominent symptom of cervical catarrh, a profuse cervical leucorrhea, is produced. This discharge resembles the normal secretion of the cervical glands. In its physical properties it is characteristic. It is a thick, tenacious mucus, and differs decidedly from the thin, more serous discharge from the vagina or from the body of the uterus. The discharge is often opaque; it is rarely purulent, and is very rarely streaked with blood. The mucous membrane of the cervical canal becomes swollen, and may project or prolapse beyond the limits of the external os, so that the external os has around it a ring of red congested mucous membrane. A similar condition is observed on theeyelids in conjunctivitis. Such a prolapse of the mucous membrane would bring the orifices of some of the racemose glands upon the vaginal aspect of the cervix, where it will be remembered they are not normally present. The inflammatory action extends beyond the limits of the external os on to the vaginal aspect of the cervix. The squamous epithelium exfoliates over a limited area around the external os, and there is produced an erosion resembling that already described under Laceration of the Cervix. Consequently, the red eroded area surrounding the external os that appears in many cases of chronic inflammation of the cervical mucous membrane is due to extension of the inflammatory process on to the vaginal aspect (with desquamation of the superficial squamous cells) and to prolapse of the mucous membrane of the cervical canal. The racemose glands may become obstructed, either as a result of thickening in the character of the secretion or of occlusion of the orifices, and small retention-cysts are formed, which often fill the body of the cervix, and, extending peripherally, appear beneath the mucous membrane of the vaginal aspect. The cervix is then said to have undergone cystic degeneration. Deep-seated inflammatory changes may also take place as a result of cervical catarrh, so that at first a slight hypertrophy from inflammatory exudate results, and later the formation of connective tissue produces a sclerotic condition of the cervix.

As has been said, chronic cervical catarrh, unless of gonorrheal origin, is nearly always secondary to some local or general condition. The most usual cause of the disease is laceration of the cervix, which causes inflammation of the mucous membrane by direct injury and exposure.

The various flexions and displacements of the uterus are often accompanied by cervical catarrh, which probably is caused by the chronic congestion brought about by interference with the circulation of the body and cervix. The use of frequent douches of cold water to preventconception is said to result in chronic inflammation of the cervical mucous membrane.

Imperfect involution after labor, miscarriage, or menstruation may cause cervical catarrh from the chronic congestion that results.

Gonorrhea seems in many cases to be communicated directly and primarily to the cervical mucous membrane, and results in a most obstinate form of chronic inflammation.

The scrofulous and tubercular diatheses seem undoubtedly to predispose a woman to chronic inflammation of the mucous membrane of the cervix, as of other mucous membranes of the body. Cervical catarrh often appears in such women without any local lesion to account for it. The severity of the local trouble depends upon the general condition, diminishing when the general health improves.

In all cases of cervical catarrh, even though dependent upon a distinct local lesion like a laceration of the cervix or a flexion of the uterus, the severity of the catarrh, as measured by the quantity of the discharge, is very much dependent upon the general health. The woman is often troubled by leucorrhea only at those times at which her general health is impaired by overwork, anxiety, or from some other cause; and even though the disease may be apparently cured by appropriate treatment, the symptom, leucorrhea, is very apt to reappear whenever the woman is subjected to such depressing influences.

The most conspicuoussymptomof cervical catarrh is the leucorrhea—the discharge from the cervical glands. As has already been said, in its physical properties it is characteristic. It is a thick, opaque, tenacious mucus. The quantity is often so great that the clothes of the woman are soiled and she is obliged to wear a napkin.

There may be present slight backache and a feeling of vague discomfort or pain in the pelvis as a result of the inflammation of the cervix. It is difficult, however, to separate symptoms referable distinctly to the cervicalinflammation from those due to the primary trouble, to which the cervical inflammation is also to be attributed. The only one distinct symptom of cervical inflammation is the leucorrhea.

Digital examination in a case of cervical catarrh usually reveals an altered condition of the cervix. The vaginal cervix may be somewhat enlarged and soft in the early stages of the disease, or cystic and sclerotic in the later stages. The external os is usually enlarged, often admitting the tip of the index finger even in those who have not suffered with laceration of the cervix. The prolapsed mucous membrane is present, and the erosion may be readily felt around the external os, being easily distinguished from the smooth, less velvety squamous mucous membrane of the vaginal aspect.

Speculum examination shows a congested vaginal cervix and a patulous external os around which is the red erosion already described. Escaping from the external os is seen the thick cervical mucus, which is often so tenacious that it may be lifted from the cervical canal with forceps.

The diagnosis of cervical catarrh is usually very easily made from a consideration of the signs described. The important thing in any case is to determine the cause of the inflammation of the cervical mucous membrane, in order that the proper treatment may be directed to it.

Treatment.—As has been said, cervical catarrh is always secondary to some local or general condition, except in the case of direct gonorrheal infection. The gonorrheal cases must be determined by the history of the disease and by the distinctive signs of gonorrheal infection which will be described later.

In every case of cervical catarrh a thorough examination to determine the local cause of the disorder must be made. If, as will usually be the case, such a local cause is discovered, the treatment should be applied to it, and the inflammation of the mucous membrane may be disregarded, with confidence that it will disappear when theexciting cause is removed. Many cases are treated by local applications, the whole attention of the physician being wrongly directed to the secondary condition, while the exciting lesion, such as laceration of the cervix, subinvolution, or a flexion or version, is neglected. Such treatment, of course, results in but temporary benefit.

Besides such cases of chronic local inflammation dependent upon a distinct local lesion, there are many others in which the catarrh is but a local manifestation of a general state of depressed or poor health, or of a distinct dyscrasia like tuberculosis, syphilis, or scrofula. Local treatment in such cases, to the neglect of the general health, is wrong.

If the advice here given—to seek for the primary cause of the cervical catarrh and to cure it—is followed, it will be found that there are but very few cases that depend for cure upon local applications. Simple local treatment by douches, etc. may, however, be valuable aids in hastening the cure of the disease after the exciting cause has been removed.

The treatment may be considered under two heads, the general and the local treatment.

General tonic treatment is required in most cases of protracted cervical catarrh. The preparations of iron are the most valuable in this condition.

The contraindication to the use of iron in uterine disease is menorrhagia or metrorrhagia—profuse bleeding from the uterus. If in any case this symptom is present, and it is found that the bleeding is increased after the administration of iron, then this drug should be discontinued.

The following are useful prescriptions in those cases in which iron is indicated:

Bland’s pill, the prescription for which may be written:

Basham’s mixture, the formula for which is—

The prescription which Professor Goodell called the “mixture of the four chlorides” is—

This prescription should not be given for more than two weeks at a time.

Careful attention should always be paid to the regularity of the bowels, in order to prevent pelvic congestion, which may result from constipation.

Two or three drams of Rochelle salts may be administered in a tumblerful of water every morning, one hour before breakfast.

A useful prescription, combining the saline purgative and the iron, is—

An excellent laxative pill is—

Sig. One pill three times a day.

Strychnine in addition to the iron is often a most useful medicine in cervical catarrh.

Various medicines have been administered internally to control the hypersecretion from the cervical glands. Such therapeutics, however, is not to be relied upon.

Any distinct pathological condition, like tuberculosis or syphilis, should, of course, receive the appropriate treatment.

Local treatment may be directed to the vaginal aspect of the cervix or directly to the cervical canal. The former treatment should always be tried first, and it will usually be found sufficient. It consists of the administration of hot vaginal douches, the application of Churchill’s tincture of iodine to the vaginal vault, and the use of the glycerin tampon as described under the treatment of laceration of the cervix. Puncture of the cervix in order to produce local depletion, as already mentioned in the preparatory treatment of laceration of the cervix, may also be tried.

If any case of cervical catarrh persists after the cure of the primary local or general lesion, in case such a lesion is present, and after the additional local treatment by douches and applications to the vaginal vault, then we may be obliged to make applications directly to the mucous membrane of the cervical canal.

These applications should be made as follows, any time in the menstrual interval being appropriate: The cervix should be exposed through the Sims or the bivalve speculum, and should be steadied by seizing it with a tenaculum. The cervical canal should then be wiped out with cotton either in the grasp of long thin forceps orupon an applicator. The cervical mucus should be removed in this way, in order to permit the direct application of the desired solution to the mucous membrane. The applicator or forceps, armed with cotton saturated with the solution, should be introduced in the cervical canal and applied to all portions of the mucous membrane.

In place of the applicator we may use the glass pipette or instillation-tube (Fig. 110), as recommended by Skene. This instrument, charged with a few drops of the solution, should be introduced as far as the internal os, and the solution should be expressed as the pipette is slowly withdrawn.

Fig. 110.—Instillation-tube.

In most cases of cervical catarrh the external os is sufficiently large and the canal sufficiently patulous to permit the applications already described. Sometimes, however, when the external os and the canal are contracted, it is desirable to dilate slightly with the small uterine dilators before making the application. Such dilatation to one-quarter or one-half an inch may be performed without an anesthetic, and may be repeated as often as necessary.

Various solutions are used for application to the cervical canal. Violent caustics should be avoided. The solutions of mild strength are preferable. A solution of 1 or 2 grains to the ounce of chloride of zinc, sulphate of zinc, tannic acid, nitrate of silver (5 to 10 per cent.), or bichloride of mercury (1:1000) is often useful. An application of pure carbolic acid is sometimes followed by good results. Perhaps the most generally useful application is Churchill’s tincture of iodine or a solution of 2 parts of tincture of iodine and 1 part of carbolic acid.

In describing the lesions of laceration of the cervix and cervical catarrh, frequent mention has been made of the cervical erosion or the catarrhal patch. The erosion, or red granular area, surrounding the external os seems to be caused by various factors. In laceration it is due to the eversion and exposure of the normal cervical mucous membrane, and perhaps to slight proliferation of the cylindrical cells of this mucous membrane on to the mucous membrane of the vaginal aspect of the cervix. In cervical catarrh it is caused by swelling and prolapse of the mucous membrane of the cervical canal, and extension of the inflammatory process beyond the limits of the external os, with partial desquamation of the squamous cells.

There are other cases, however, in which the erosion appears to be congenital. Such erosions have been observed by Fischel and other investigators surrounding the external os in new-born infants. Erosion of this character has been found, in a more or less marked degree, in 36 per cent. of new-born infants. Microscopically, these erosions appear to be a direct continuation of the mucous membrane of the cervical canal. They are covered with a single layer of cylindrical epithelium, and they possess mucous glands, resembling in these features the cervical mucous membrane, and not the mucous membrane of the vaginal aspect of the cervix, which, it will be remembered, is covered with squamous epithelium and contains no glands. This congenital erosion usually is of very limited extent, but in some cases it covers the greater part of the vaginal aspect ofthe cervix, and may then give rise to decided symptoms. The condition is due to imperfect development of the external os. In the well-formed woman there is, at the external os, a sharp line of demarcation between the squamous epithelium of the vaginal aspect and the cylindrical epithelium of the cervical canal. In the congenital erosion the epithelium of the canal extends beyond the limits of the external os, and meets the squamous epithelium at a lower level than normal.

Such congenital erosions usually give rise to no trouble, though perhaps they predispose the woman to cervical catarrh as a result of exposure of the mucous membrane. In extreme cases, however, in which the cylindrical epithelium of the cervical canal persists over the greater part of the vaginal cervix, and in which the glandular elements of the canal are found on the vaginal aspect, a distinct pathological condition arises. The symptoms of this condition resemble closely those of laceration of the cervix with ectropion. There is backache, a feeling of weight in the pelvis, and perhaps some ovarian pain. In addition, the woman complains of a leucorrhea presenting the characteristics of the cervical mucus. Decided nervous and digestive disturbances may be present.

If this condition of congenital ectropion exists along with a laceration of the cervix, the diagnosis becomes very difficult. If, however, we can exclude the possibility of a former conception, we may by careful study determine the real nature of the case.

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