exciting 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:

Blaud's pill, the prescription for which may be written: R. Pulv. ferri sulph. exsic.,

Potass. carb. puræ,

āā. 3ij.

Ut fiat. massa dividenda in pilulas No. xlviii.

Sig. One pill three or four times a day.

The prescription which Professor Goodell called the "mixture of the four chlorides" is

R. Hydrarg. chloridi corrosivi,

Liq. arsenici chloridi,

Tinct. ferri chloridi,

gr. j-ij;
gtt. xlviij;

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

M. Sig. One tablespoonful one hour before meals.

An excellent laxative pill is

R. Extract. colocynthidis,

Extract. hyoscyami,

Massæ hydrargyri,

ăā. gr. x;

gr. xx.

M. Fiat massa dividenda in pilulas No. xx.
Sig. One pill three times a day.

Strychnine in addition to the iron is often a most useful medicine in this condition of 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 or

upon 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.

LENTZ&SONS

FIG. 110.-Instillation-tube.

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.

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.

The

Various solutions are used for application to the cervical canal. Violent caustics should be avoided. 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, or bichloride of mercury is often useful. An application of 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 I part of carbolic acid.

CHAPTER XIV.

CONGENITAL EROSION AND SPLIT OF THE CERVIX.

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 of