C~ C( c "V"-. ------------ Mr. President : In response to the invitation with which I have been honored I propose briefly to present for considera- tion of the Society the surgery of the cervix in connection with the treatment of certain uterine conditions familiar to all. As it is the wish of others that I should place on record my views resulting from personal observation on these points I state the fact, that the plea may shield me from the charge of egotism. Division of the cervix for the relief of dysmenorrhoea and sterility has been a favorite practice for years past with many of the profession. Scarcely any operation in surgery, however, has been proposed where so little judgment, as a rule, has been exercised and where so frequently its indiscriminate perform- ance has even amounted to malpractice. A reaction has slowly taken place in the views of the profession regarding this oper- 4 ation, but from one extreme we may fall into the opposite error, as we have certain conditions of the uterus which cannot be relieved otherwise than by a division of the cervix. Experience has taught us that both dysmenorrhoea and steril- ity exist frequently from causes having no connection with flexure or even with the uterus itself; that dysmenorrhoea is not always present with a flexure, while impregnation some- times takes place when this deviation is well marked. As the uterus is an erectile organ, the existence of a flexure, and one frequently varying in degree, may be due to a tempo- rary interference with the circulation from faulty nutrition. In these cases the flexure is above the vaginal junction, and unless the disease has been of so long standing that a loss of substance with fatty degeneration from pressure has taken place in the angle, the curvature will lessen in proportion to the relief of the local disease; therefore surgical interference would be un- justifiable in this chordee, as it were, of the organ, except as a last resort after careful constitutional and local treatment had failed to relieve the condition. An effort must be made at first to improve the general health, or in other words the nutritive functions, and to equalize the circulation by means of proper baths, frictions to the skin, &c. Too much stress is frequently laid upon the importance of a detected erosion or so-called ulceration of the neck, when the condition of the cervix is generally but an effect, and not the cause. Follicular disease usually exists in some portion of the canal above, which may have involved or not the submucous tissue, but as to the exact seat or extent, we cannot in practice draw the line with any accuracy. In the condition known as endometritis with flexure I am in the habit of using large vaginal injections of hot water once or twice a day, with the 5 temperature increased from 98° to 104° according to the ur- gency of the symptoms. A small injection of water at an ele- vated temperature will at first increase the engorgement, but if its action be prolonged sufficiently contraction of the vessels takes place and the vagina will be found corrugated, as if after the use of an astringent. I am satisfied that although the use of cold at first produces the same condition, yet after reaction takes place the pelvic vessels really become more engorged than before. By means of injections and a close attention to the general condition we must at first prepare the patient for the local treatment. For the latter purpose I prefer the use of a solution of chromic acid, Churchill's strong tinct. of iodine, the persulphate of iron, and various other astringents, according to circumstances. These remedies are to be applied to the uterine canal by the aid of two instruments—the uterine probe and the applicator. These I may claim as my own, so far as having reduced the size of the uterine sound to that of the sil- ver probe now in general use, and having substituted a ductile silver instrument as the applicator in the place of the whale- bone staff used many years by Dr. Sims for the same purpose. The probe is to be used for the purpose of obtaining the exact sweep of the canal, which cannot be done with the same ac- curacy by means of a stiff sound, inasmuch as the latter will force the organ to conform to the existing curve of the instru- ment. It may be a matter of opinion as to the practical import- ance of this point; apart, however, from the greater facility gained in making the application, by having obtained the exact curve, I conceive that the patient is spared an amount of pain, while an additional source of irritation is avoided by not dis- turbing, at this stage, the position of the uterus. A little cot- ton is first carefully to be twisted for two inches or more around 6 the applicator, the proper curve is then to be given it from that of the probe, and with the cotton moistened, but without an excess of liquid, it is passed to the fundus. To do this prop- erly, however, the uterus must be steadied during the opera- tion by seizing the cervix with a tenaculum. The patient should be placed in bed immediately after the use of chromic acid, guarded against cold, and not allowed to sit up until the effects of the application have passed off. Later in the treat" ment it may be advisable, if the uterus has been reduced to a less irritable condition, to resort to sponge-tents for dilating the canal above the internal os, so that injections maybe used with safety of iodine, the persulphate of iron, &c.—a mode of treat- ment which, by unfolding a greater surface, is frequently fol- lowed by very satisfactory results. Twice a month is as often as these injections should be made, so that the general health of the patient may not become impaired by too close confine- ment ; yet absolute rest is of the greatest importance so long as any irritation resulting from the treatment remains. This course is to be persevered in, with the daily vaginal injections, while every habit of life is regulated, and the moral condition of the patient—a most important element—should be equally cared for. After a reasonable time, if there has been an improvement in the local disease and yet the flexure continues unchanged, with persistent dysmenorrhoea, it is reasonable to attribute the cause to a mechanical one, and a division of the cervix is not only justifiable but I deem it the duty of the physician to have recourse to it. There are many, I am aware, who con- scientiously oppose all operative procedure, under any circum- stances, and would either abandon the case to the course of nature, to result in atrophy of the uterus early in life, and 7 likely phthisis in addition, or will resort to the use of the inter- uterine stem as a means attended with less risk to the patient. I have observed instances of long toleration of this instrument, and without bad results following its use, in the hands of skill- ful men, yet I have never known an instance of permanent rectification of a flexure resulting from loss of substance in the uterus, while it is my belief that as a consequence from its use pelvic cellulitis is the rule and not the exception. I beg that I may not be misunderstood, for I have stated that I regard, as a rule, a curvature of the uterine body as being a temporary result of disease, the effect and not the cause; therefore a mere division of the cervix under any circumstances cannot be relied upon as a sole means of relief. And, moreover, that it is against the indiscriminate practice of the operation that I offer my protest, in resorting to a means which, without judg- ment as to its propriety or the necessary preparatory treatment before its performance and proper care afterward, is so fre- quently attended with the most serious results. I repeat, expe- rience has taught us that a simple flexure above the vaginal junction will gradually disappear if a proper treatment of the uterine disease can be instituted, and that in this condition it is always an exception to the rule where it becomes necessary to resort to surgical means. Such is not the case, however, when the flexure is below the vaginal junction; here we find the body of the uterus in position at a right angle to a long and pointed neck presenting in the axis of the vagina. This con- dition I regard as congenital, or rather having its origin pre- vious to puberty, when an undue development of the neck took place in proportion to the body. Both dysmenorrhoea and sterility, as a rule, exist in this condition, with but little or no uterine disease until at a somewhat advanced period of mar- 8 ried life. This is the commonest cause of sterility when due solely to a mechanical condition, and when the neck can be di- vided at an early period of womanhood the result has invaria- bly proved in my experience most satisfactory. After some years of married life we have a condition, in addition, to deal with due to ovarian influence: the uterus having been long obstructed in a natural performance of its function, atrophy re- sults. The cervix should be divided as a first step, for even at an advanced period the organ may yet be restored to a proper size and to a normal state of its function by means of sponge- tents, electricity, and other means. I am unable to speak from statistical authority, for it has been impossible to keep any sat- isfactory record of scattered cases upon which I have operated during a series of years past for flexure below the vaginal junction; but my impression is that fully two out of three among the married, under the age of twenty-five, have become pregnant within the first year after the operation, and that the relief of dysmenorrhoea has been quite as satisfactory. The operation is also a proper one sometimes in anticipation of the future, in certain cases, where no flexure exists, but the neck is too long in proportion to the natural size of the body. In this condition, with the neck resting on the recto-vaginal septum or floor of the pelvis it is impossible for the uterus long to pre- serve its natural position, especially in the married woman, for the fundus becomes thrown backward, as the neck naturally turns to the axis of the vagina in a direction offering the least resistance. This is the first stage of retroversion, for by de- grees the fundus becomes crowded over into the hollow of the sacrum, from habitual constipation and other causes. In the descent of the body, the neck is kept steadily pressed upward against the anterior wall of the vagina, fatty degeneration with 9 absorption slowly takes place at the point where the pressure which is exerted from each extremity of the organ becomes con- centrated, and a retroflexion is the result. In due time atrophy of the neck occurs, while the body of the uterus becomes hyper- trophied from obstructed circulation and frequently perimetritis. In this condition, before flexure has taken place, without the neck is unusually long, amputation is unnecessary, for if the circular fibres are divided entirely through on one side the longitudinal ones will gradually contract until the neck be- comes of a natural length and thickness. I must now refer to the mode of operating. Except in cases of constriction of the os following the use of nitrate of silver, or from other causes, and where it becomes ad- visable to divide the neck in the treatment of fibrous tumors, I never now incise the cervix laterally. In fact this operation for the relief of flexure I have never performed, I believe, over half a dozen times, as the result has been uniformly unsatisfac- tory. My experience has therefore been confined to observing the bad consequences following this operation in the practice of others. If a flexure above the vaginal junction exists in either anteversion or retroversion of the uterus, a lateral division of the cervix can accomplish but little, as the constricted point cannot be reached effectually. In fact except in rare instances, where the deviation has been slight and impregnation takes place by chance immediately after the operation, nothing more is ever gained than a temporary effect due to the revulsive action attending the process of reparation. Were it possible to divide the canal freely on both sides to a point even beyond the seat of flexure, the passage would not be open, as the sides of the canal are kept by pressure still in close contact, although a sound might be readily passed. Nothing under any circum- 10 stances can be hoped for from the operation without a free in- cision on both sides is made down to the vaginal junction, but after this has been done other difficulties of a serious character arise as a consequence which more than counterbalance any temporary advantage. But I shall again refer to this subject when treating of lacerations of the cervix following parturition. A division of the cervix should not be attempted in any case when the existence of perimetritis is suspected. If this rule be observed and the patient with anteflexion has been properly prepared for the operation which I shall describe, it is attended with'as little risk of life or bad consequences as any in minor surgery, while we are all probably familiar with instances to the contrary where this rule has not been observed. I prefer to place the patient on the left side for the operation, with the parts exposed by means of Sims' speculum; while the anterior lip is steadied by means of a tenaculum and drawn gently forward, a uterine probe is to be carefully introduced and its curve modified until the true sweep of the canal has been obtained. The probe is held with the tenaculum in the left hand, as a limb of the scissors, adapted for the purpose, is intro- duced along its course in the canal as a guide. The posterior lip is now divided backward in the median line, nearly to seve- ral little radiating folds formed just at the vaginal junction, by drawing the neck forward. These folds, when present, are an unerring guide in avoiding the circular artery, and are seldom absent. If the flexure is in the cervix, the operation has been accomplished by a single cut. If its seat, however, is above the junction of the vagina, we must have recourse to the knife. Some years ago I had the little blade of Sims' instrument con- structed into a ball and socket jointed knife, which combined the advantages of his two instruments in one, by allowing the 11 blade to be set at any angle. On proceeding with the opera- tion, witrfout removing the tenaculum or probe, the blade is passed along the latter as a guide, with its cutting edge set back- ward, for the purpose of dividing the little triangular space formed by the sweep of the point of the scissors in an arc of a circle. When this has been accomplished it is an exception to the rule that a sound of the natural curve cannot be passed to the fundus. However, with the flexure high up and at a sharp angle we are obliged to divide the angle anteriorly. Using the probe still as a guide, the blade of the knife is set at a proper angle with its cutting edge forward, and as it passes the flexure a division of the angle by the width of the blade in its passage will be sufficient. The open canal should be firmly packed with little pledgets of cotton soaked in glycerine and over all the vagina tamponed as if hemorrhage at the time actually existed. This precaution is of the greatest importance, for a divided vessel in erectile tissue may contract promptly at first, but with reaction after the operation bleeding comes on sud- denly, and the mouths of the vessels enlarge in a remarkable manner from the force and continuance of the current Before this lesson had been learned I have spent hours in arresting a hemorrhage which jeopardized life when at the time of the operation the loss of blood had been insignificant. The patient should be placed at once in bed, every precaution taken to guard against cold, and under no circumstances should she be allowed to get up before the tenth or twelfth day after the opera- tion. On the third day the cotton should be carefully removed from the vagina, a fresh glycerine dressing placed over the cer- vix, and the tampon replaced. Daily this is to be removed, but the plug in the divided cervix should not be disturbed until freed by suppuration. Afterward, until healed, a sound is to 12 be carefully introduced above the seat of flexure and withdrawn so that its extremity is made to pass in the angle %long the course of the incision, to retard its closing at this point. A fresh pledget of cotton saturated with glycerine should then be introduced into the cervix, and the tampon replaced. After a week, if there is no tendency to bleeding, a daily glycerine dressing with a little tannin in solution, placed over the divided surfaces, will be sufficient, and, if needed, a single application of a weak solution of nitrate of silver to hasten the healing. I have been frequently charged with being too careful after this simple operation, but pelvic cellulitis, followed by abscesses, occurs often after slight exposure, and I have known several instances of death as the result of general peritonitis from the same cause. Formerly I divided the anterior lip in the median line for the relief of dysmenorrhoea depending upon retroflexion, and, at least in theory, the operation seemed quite as applicable as for the opposite condition in anteflexion ; but I have long since abandoned the operation, for reasons which I will subsequently state. We rarely find an instance where the fundus has re- mained in the hollow of the sacrum for any length of time without a marked exaggeration of any previous disease exist- ing, while, in addition, there becomes established some new complication of a more serious character, due to obstructed circulation. As the fundus is crowded by degrees lower in the pelvis from pressure above, the organ becomes flexed, as we have already remarked. If menstruation did not occur, the difficulty would remain a mere mechanical one, but as this function cannot be properly performed the flow, with dysmen- orrhoea, is either excessive or scant. In either condition, the organ and surrounding tissues remain in a state of chronic en- 13 gorgement, and as a consequence this state of the circulation cannot long exist without the occurrence of perimetritis, and frequently pelvic cellulitis, to a greater or less extent—so long as the organ remains retroflexed, and after this inflammatory condition has been once established it seldom, I believe, sub- sides entirely during the menstrual period of the female, or at least it requires but a slight provocation to light up again the disease. I have had, to my sorrow, pelvic cellulitis with abscesses frequently to occur, and death in one instance, after the most careful preparatory treatment previous to operating, when, at the time, there was not the slightest indication of danger. In fact I am unable to recall a single instance where inflammatory symptoms did not occur if an attempt was perse- vered in to keep open the incision while the uterus remained in this position. Retroflexion, however, can be cured by the long-continued use of hot water injections and hot baths blistering the neck occasionally to deplete by the watery dis- charge, daily glycerine dressing, and by a careful attention to the state of the bowels and general condition. By degrees, as the tenderness on pressure subsides, the fundus should be lifted day after day, as far as prudent, without attempting too much at any one time, with a finger of one hand in the rectum to lift the fundus and gently press the organ forward from out of the hollow of the sacrum; the cervix can be depressed in the opposite direction by a finger of the other hand in the vagina. I have succeeded, after months of careful daily manipulation, in restoring the uterus to position, with the gradual disappear- ance of a marked flexure, when in the beginning the organ was apparently bound down by adhesions. Sometimes when the parts are yet too tender to be manipulated by the rectum I have resorted to the aid of atmospheric pressure, by a method 14 which has at times proved very satisfactory in my hands for correcting the displacements resulting from accidents or from a fibrous tumor in the posterior wall. About two years ago I was consulted by a patient after a miscarriage, with the uterus enlarged and completely retroverted, while so much tenderness on pres- sure existed that a reduction by means of the elevator was deemed too hazardous. With all her garments loosened about the waist she was placed on the knees and elbows, for the purpose of lifting the fundus, by the aid of gravitation and pressure of a sponge probang from the rectum. As Sims' speculum was introduced the rectum became distented with air, while the uterus was pressed so far toward the pubes that I was unable to get under it. The instrument was consequently withdrawn and introduced into the vagina. To my surprise, as the air distended the vagina the neck of the uterus, which was behind the pubes, was carried toward the hollow of the sacrum, and the uterus was in position without the aid of direct manipula- tion. I have since ascertained that this cannot be accomplished where laceration of the perineum exists so as to leave the vaginal outlet patulous, or when air has been admitted to the vagina previous to the introduction of the speculum into the rectum. My objections to the lateral operation, in connection with the after effects as an exciting cause of disease, is due to the fact that if gaping of the flaps occurs a tendency exists to a rolling out of the lining membrane of the canal. An erosion extend- ing into the canal is soon established, which will recur as often as healed, with the result in time that the whole organ becomes hypertrophied. This source of irritation is due to the fact that whenever the female is on her feet the v flaps become separated from pressure on the posterior wall of the vagina. 15 The everted lips in due time become softened and flattened down so as to lose all appearance of ever having been in con- tact. I have seen this condition presenting the appearance of an enormous cervix over two inches in diameter, with the whole organ enlarged and every attempt at treatment proving a failure until the true condition was appreciated. I have fre- quently observed the same effect following lateral laceration of the neck as a result of parturition, and to some extent where but one side had been involved. No such tendency to gaping occurs when the neck has been divided or lacerated in the antero-posterior diameter, for the surfaces are kept well together by pressure of the vaginal walls. In fact it is seldom, when the accident occurs in this direction during childbirth, unless complicated by a vesico-vaginal fistula as a source of irritation, that the surfaces do not rapidly unite. When lacerated later- ally, and the case has been one of long standing, the edges of the neck will be felt projecting beyond the vaginal junction as the top of a half-grown mushroom over its stalk. I invariably bring about a union of the two surfaces before attempting any other treatment whenever I have met this condition in practice, whether the result of surgical interference or a consequence of labor. While the two lips are held by the hand of an assistant in contact by means of tenacula I slip a loop of wire around the neck with both ends passed through a canula to act as a tourni- quet. Before tightening the loop, however, a portion of the vaginal wall should be drawn up over the ring so as to leave the flaps above perfectly free. This simple instrument is secured by bending each end of the wire back over the extremity of the canula. The flaps are then allowed to separate and the whole surface is freely denuded by means of scissors, with the excep- tion of a straight strip about a third of an inch in width from 16 before backward, which is to form the cervical canal. The neck is transfixed on a line with the bottom of the angle between the two sections by a large needle armed with a silk loop, and this is drawn through with a silver wire attached. Two or three deep interrupted sutures are to be thus introduced on each side of the canal and each twisted so as to bring the corresponding surfaces accurately together; they are then to be bent over flat to the surface and cut off at half an inch in length. The space intended for the os should be about twice the width left between the respective sutures, so as to leave the opehing of a sufficient size after the enlargement of the neck has been reduced. On freeing the loop it will be found that no bleeding will occur, while this instrument, by controlling it during the operation, added greatly to the facility of its performance. The patient should be kept in bed ten or fourteen days after the operation, and the sutures removed on the eighth day. Amputation of the cervix is unnecessary except for the removal of cauliflower growth, malignant disease, or the develop- ment of the neck met with where the excessive growth is some- times several inches in length. The method introduced by Dr. Sims some years ago, of covering the stump with the vaginal tissue so as to obtain union by the first intention, has proved of the greatest value. The condition recognized as malignant I believe to be, theoretically, at least, a purely local dis- ease at an early stage of development, and if healthy tissue could be reached at the time of removal a return of the disease would not occur; but unfortunately, in the absence of all premonitory symptoms, the condition is neither recognized nor suspected until the disease has so far advanced that the surrounding tissues have already become infiltrated when apparently still in their integrity. Therefore, while it is 17 eminently proper that the patient should have the benefit of the doubt in an early resort to the aid of surgery for removal, the prognosis must always be an uncertain one in each individual case. When the disease, however, has so far advanced as to involve the neck to the vaginal surface, and the mobility of the uterus has become impaired, it is best, as a rule, I believe, not to interfere, for although a temporary benefit is frequently gained by an improvement in the general health, yet the disease soon returns and then seems to run its course with greater rapidity. When the surface has been left to heal by granula- tion it has been my experience, I think, to observe an earlier return of the disease than in other cases where the stump has been covered by healthy tissue and union by the first intention obtained. That the cauliflower growth, at least, is a local disease in the early stages, I am persuaded from the fact that in several cases where I had been able to amputate the neck beyond in healthy tissue, while the disease was yet limited in extent, and afterward covered the stump, no return has occurred, although several years have elapsed since the operation in each instance. These cases have been, however, unfortunately but exceptions to the rule, as the disease has returned in the majority of instances between the fourth and sixth months after removal. When surgical interference has been determined upon, with the aid of the loop already described to control the hemorrhage, I prefer a pair of scissors for removing the cervix to an ecraseur. The operation can be concluded in a shorter time, without the risk of cutting through into either the peritoneal cavity or bladder from the loose tissue of the vagina being drawn within the grasp of the chain. Generally two sutures on each side of the uterine canal are sufficient, and if the surrounding tissue has been well drawn up before tightening the loop the vaginal 18 surface will readily cover the stump as a flap in a circular amputation. One precaution is necessary in passing the sutures, so that the vaginal tissue should alone be included, for if the substance of the uterus is also taken up the flap will remain fixed. After the sutures have been twisted and bent over flat the loop can be removed, when the lateral tension from the pelvic fascia will be sufficient to control all bleeding by keeping the two surfaces in contact. Amputation of an elongated neck is to be performed in the same manner. But to judge of its true length, as a precaution it is well to place the patient on the knees and elbows before operating, for the neck is always apparently longer than in reality from prolapse of the uterus. When in the position favoring gravitation of the uterus and the vagina distended from atmospheric pressure the exact length of the neck from the vaginal junction can be accurately noted. This precaution is a necessary one, for the peritoneal cavity has been entered when the amputation has been attempted at a point apparently far distant from the vaginal junction. We are all familiar with a condition of the cervix resulting from a long-continued use of the nitrate of silver, caustics, and the cautery. The neck is found smooth and hard, in fact a mass of cicatricial tissue. The female has been assured of her recovery on the disappearance of the erosion, while from her own feelings her condition is a miserable one if her health has become impaired. Apart from a sense of weight, which is not, however, always present, with increased nervousness, she suffers from shooting pains about the pelvis, which she is generally un- able to locate, or they may exist as neuralgia in some part of the body remote from the seat of irritation. The neck of the uterus may be compared to the condition known as an irritable stump 19 where some nerve filament has been involved in the cicatricial line after an amputation. Change of air or any other means resorted to by which the general health may be improved will mask for a time the local condition, but she will remain sterile and subject to a return of the enemy whenever her health be- comes again enfeebled. When the case is not an aggravated one, hot water injections and blistering the cervix with the acetic solution of cantharides, as the local treatment, will, in time, frequently bring about a change for the better. As a rule, however, there is no radical relief except from surgical interference. Formerly it was a practice to remove the greater portion of the neck, leaving the uterus afterward in a condition subject to be displaced in any direction from the loss of vaginal support. It is not necessary to do more than remove with scis- sors a thin section from the entire surface to a limit at which the surrounding tissue can be found free enough to be drawn over the stump. The sutures are to be introduced and the flap secured in the same manner as described in the operation for amputation. Although the deeper structure may have become equally involved with the vaginal surface, yet after removing the latter below the sub-mucous tissue and transplanting a new set of follicles the reparative process will gradually be brought about. From cystic disease of the cervix the neck and body of the organ will remain hypertrophied after treatment has apparently removed all exciting cause for the condition. The eye can generally detect various little elevations on the surface of the neck, or the sense of touch may be necessary to point out the existence of these cysts which have degenerated from diseased follicles in the deeper tissues. When these are punctured a drop or two of a sero-gelatinous fluid exudes, which is found 20 by microscopic examination to be filled with fat-globules. They should be freely opened and their cavity destroyed by the ap- plication, on the point of a probe, of the persulphate of iron or the strong tincture of iodine. When this condition has been of long standing and left to nature these degenerated follicles empty themselves one after another until the surface becomes deeply pitted and hard—the neck atrophied—with the body of the uterus at length in the same condition. At any time dur- ing the progress of this diseased condition the female may suf- fer from the same train of symptoms as I have described in connection with the generation of cicatricial tissue from other causes. The remedy is the same, and with a fresh set of folli- cles the organ is frequently again restored to a healthy condi- tion. I consider a successful termination of the treatment of u+~rine disease to be just in proportion to the amount of induration remaining afterward; for it is impossible for the uterus to per- form its function properly if the cervix is left to a great degree a mass of cicatricial tissue, and sterility must invariably exist. Moreover, this condition, whether the result of disease over- looked or from local treatment, is certainly an exciting cause of irritation to the nervous system, so that indirectly the nutri- tive functions become impaired and tuberculous deposit is fre- quently a consequence. I am satisfied that this statement is not an exaggeration, for although we are all familiar with instances where females have remained comparatively well after every portion of the uterus within reach of art has been reduced to cicatricial tissue, yet this is not the rule. I am no extremist, and would add nothing in the balance to favor the views of those 'who deprecate the use of the speculum; for observation has taught me that these diseases cannot be sue- 21 cessfully overcome except by careful local treatment from the beginning, with a thorough and practical knowledge of the whole field of medicine to aid in restoring the sympathetic functional derangement of the general system. As a surgeon, I have always been conservative, and have never resorted to the practice except as a last resort. I must acknowledge, how- ever, that I am forced to have recourse to it, and that my inge- nuity is oftener taxed to repair the damages inflicted by means used to afford relief than from the result of disease uncompli- cated. It is the practice of too large a proportion of the profession to direct all their local treatment to the observed condition of the neck, while if it is but the outcropping of the disease within the canal, even when healed, a temporary result only is gained, as a relapse will occur. While, on the contrary, if the condition within the canal is cured an erosion on the neck will generally heal by the use of warm water injections to keep the parts clean, without any direct application. The nitrate of silver in the solid form is in more common use from its sup- posed mild action than any other agent for local treatment; yet from indiscriminate and too frequent use it has done more harm than any of the strongest caustics. I grant that its use will heal an erosion promptly and sooner, probably, than any other means that we have at command, but it is accomplished too frequently at the expense of an impaired vitality of the parts. Its use I have almost entirely abandoned, and confine myself chiefly to a solution not stronger than forty grains to the ounce, to aid the action of some previous application. It is not that I would so much deprecate its use in the hands of an expert, but, from its convenient form, it is too great a temp- tation for many who are the most ignorant to flatter themselves 22 that they have mastered the art as a specialty when once in possession of a porte-caustique and a speculum. This practice has become a scandal to the profession. I have under my care at the present time a lady who has been subjected to an appli- cation of the nitrate of silver several times a week, and fre- quently every other day, by a regular practitioner, for an erosion on the cervix, during eighteen months, the only interval being at the time of the menstrual period. The case came into my hands at length, as the disease was considered malignant from the fact that it had extended and would not heal. As I confine my local treatment chiefly to the canal I do not use any of the caustics proper, for fear of contraction from cicatri- cial tissue; although I have observed that the tendency to its formation does not exist to the same extent within the canal, after the use of proper remedies, as on the surface of the neck. We are indebted, I believe, to Dr. Sims for the introduction of chromic acid in the treatment of uterine disease It is a rem- edy which I have had in daily use for at least twelve years past, and my experience has been that its use is attended with less objection than from any other agent It should not be used of a greater strength than equal parts by weight with water. Its effect then on healthy tissue is not greater than that of the strong tincture of iodine It acts on a diseased surface as a stimulant and as an astringent, protecting it with a thin film, which usually is not thrown off from the uterine canal under a week, I am in the habit of applying it a day or two after each menstrual period, and after a week or ten days using various other remedies of a milder character as adjuvants. I think, as a rule, that we expect too rapid a result from local treatment, and are consequently tempted to resort often to stronger or more prompt means than are necessary. At best we can but expect 23 the local condition to keep pace with the gain brought about in the general condition, while an over officiousness will frequently defeat our object and retard the local improvement. Contrary to my original design, I find, from treating of sup- posed cause and effect, that I have imperceptibly entered some- what into detail of the general treatment of uterine disease. I have regretted, from the intimate connection existing, the necessity for a consideration of the subject, as the field is cer- tainly too extended a one to accomplish more than a reference to the subject in a most superficial manner. So far as I have advanced my own views, I can only state they are such as I hold at the present time; that I have endeavored honestly to judge from observation, without theoretical bias, according to the light given me, and that I hold myself open in the future to conviction if they are proved erroneous. 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